volume 31 No 2 14-12-2020

DJO Vol. 31, No. 2, October-December 2020

Mrugacz et al also divided myopes into 3 groups low myopia RNFL thinning in high myopes (Table 3) and this can be a
(<-3D), median myopia (-3D to -6D) and high myopia (>-6D). clue to differentiate it from glaucomatous RNFL thinning.
Significant difference was seen between RNFL thicknesses As we know glaucomatous optic nerve neuroretinal rim
of high myopia and control group. They found that average thinning has a characteristic pattern, inferior RNFL quadrant
RNFL thickness in high myopes was 140µ while we found area is the most affected area. RNFL thickness generally
that its 85.50µ. This difference with our study can be follows ISNT rule (inferior > superior > nasal > temporal),
attributed to lower mean age patients in Mrugazs’s study and any violation from this rule is indicative of glaucoma.30,32
(15.05years) compared to our study (26.86 years). Sihota et al29 also found that in early glaucomatous eyes the
Melo GB et al,5 Garcia-Valenzuela E et al,23 Hoh et al6 did most commonly affected area was inferior retinal nerve fibre
not find a significant association between myopia and RNFL layer. Average RNFL thickness is also significantly less.
thickness but these studies may have been limited by the Other clue to differentiate myopia from glaucomatous
poorer resolution of earlier generation OCT and confocal changes is presence of normal optic disc and visual fields in
laser devices, and thus lower sensitivity. Furthermore, the presence of moderate to severe thinning on OCT.33
ethnicity in each of these studies was different from our To conclude, we can say that though OCT is a valuable
sample. tool for diagnosing pre-perimetric glaucomatous changes
Though we have found that there is significant average RNFL but we have to be very cautious in cases of myopia. There
thinning, we thought that measurement and comparison of is definite thinning of RNFL in high myopes but we should
each quadrant of high myopes with emmetropes is important correlate with clinical findings. Though the specific pattern
to find any specific thinning, like in cases of glaucoma which of glaucomatous changes can provide clue to differentiate
shows typical quadrantic pattern. As per our study there myopic thinning from true glaucomatous thinning, as in
was significant thinning present in all quadrants except myopia retinal nerve fibre layer thinning is more generalized
temporal. (Table 3) while early glaucomatous RNFL thinning is mostly limited
In Kamath et al19 study of myopia, RNFL thickness in to superior and inferior quadrants. We should never rely
superior, inferior, nasal and temporal quadrant was 98.8µ, solely on OCT; visual field analysis and disc evaluation is
100.5µ, 58.8µ and 64.8µ respectively. They found significant indispensable in differentiating the two.
thinning in superior, inferior and nasal quadrants. They
also reported thinning in temporal quadrant but it was not But as we know that Primary Open angle glaucoma is
statistically significant. more common in high myopes (2-3 times more risk), we
Similar quadrantic difference was also found in studies should collect more normative data for myopic patients
conducted by Yi Zha et al17 D singh et al20 and Savini et al.24 and incorporate it into OCT software, to differentiate
Kang et al and Wang et al25 also found that there was thinning glaucomatous and normal thinning in myopia.
in superior, inferior and nasal quadrants (significant only
in superior and inferior quadrants) whereas in temporal Conclusion
quadrant there was significant thickening.
The above mentioned studies have found that temporal This study concludes that average RNFL thickness in
quadrant is least affected in myopia, it is even thicker high myopes is significantly low as compared to healthy
in some of the above mentioned studies. We observed individuals. But quadrant wise analysis showed that in high
insignificant temporal thinning. The increased thickness in myopes RNFL thinning was present in all the quadrants
temporal quadrant might be due to redistribution of retinal except temporal, which is different from the pattern usually
nerve fibre. As the axial length increases there is dragging
of retina towards the temporal quadrant and compression found in glaucoma patients.
of RNFL against the bundles originating from the opposite
hemisphere at the horizontal raphe which can cause temporal References
RNFL thickening. Kim et al26 and Hoh et al also supported
this theory of ‘temporal dragging of retina. 1. Lim MC, Hoh ST, Foster PJ, Lim TH, Chew SJ, Seah SK, et al. Use
Study by Moriyama et al27 imaged the shape of the globe of optical coherence tomography to assess variations in macular
in 44 highly myopic eyes using high-resolution magnetic retinal thickness in myopia. Investigative ophthalmology &
resonance images and demonstrated that myopic eyes had visual science 2005;46:974-8.
symmetrical or asymmetrical anteroposterior elongation
and posterior protrusions, which could draw the superior 2. Ho TC, Shih YF, Lin SY, Lin LL, Chen MS. Peculiar arcuate
and inferior RNFL bundles closer to the macula. This scotoma in pathologic myopia--optical coherence tomography
results in thinning at superior and inferior quadrants while to detect peripapillary neural tissue loss over the disc crescent.
dragging of temporal fibres leads to thickening temporally. Graefes Arch Clin Exp Ophthalmol. 2005;243(7):689–694.
Though the techniques of RNFL measurement are different
in Moriyama’s study but results are similar to ours. 3. Leung CK, Mohamed S, Leung KS, Cheung CY, Chan SL,
However, Leung et al 28 considered the temporal convergence Cheng DK, et al. Retinal nerve fiber layer measurements in
of the RNFL bundles as an image artifact consequential to an myopia: An optical coherence tomography study. Investigative
increase in the vertical curvature of the retina. ophthalmology & visual science 2006;47:5171-6.
Our study also supported that there’s no typical pattern of
4. Choi S-W, Lee S-J. Thickness Changes in the Fovea and
Peripapillary Retinal Nerve Fiber Layer Depend on the Degreeof
Myopia. Korean Journal of Ophthalmology : KJO 2006;20:215-9.

5. Hoh ST, Lim MC, Seah SK, Lim AT, Chew SJ, Foster PJ, et al.
Peripapillary retinal nerve fiber layer thickness variations with
myopia. Ophthalmology 2006;113:773-7.

6. Melo GB, Libera RD, Barbosa AS, Pereira LM, Doi LM, Melo
LA Jr. Comparison of optic disk and retinal nerve fiber layer
thickness in nonglaucomatous and glaucomatous patients with
high myopia. American journal of ophthalmology 2006;142:858-
60.

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7. Sengül C Özdek MÖ, Gökhan Gürelik, Berati Hasanreisoglu. tomography and scanning laser polarimetry. Br J Ophthalmol
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thickness profile in subjects with myopia measured using
8. Kremmer S, Zadow T, Steuhl KP, Selbach JM. Scanning laser the Stratus optical coherence tomography. Br J Ophthalmol
polarimetry in myopic and hyperopic subjects. . Graefes Arch 2010;94:115-20.
Clin Exp Ophthalmol. 2004;242(7):689–94. 27. Moriyama M, Ohno-Matsui K, Hayashi K, Shimada N, Yoshida
T, Tokoro T, et al. Topographic analyses of shape of eyes with
9. Mohan M. National Survey of Blindness-India. NPCB-WHO pathologic myopia by high-resolution three-dimensional
Report. New Delhi: Ministry of Health and Family Welfare magnetic resonance imaging. Ophthalmology 2011;118:1626-37.
Government of india; 1989. 28. Leung CK, Yu M, Weinreb RN, Mak HK, Lai G, Ye C, et al.
Retinal nerve fiber layer imaging with spectral-domain optical
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Ophthalmology 1999;106:2010-5. 2012;53:7194-200.
29. Sihota R, Sony P, Gupta V, Dada T, Singh R. Diagnostic capability
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domainoptical coherence tomography Indian J Ophthalmol of glaucomatous retinal nerve fiber damage. Investigative
2011;59:175-9. ophthalmology & visual science 2006;47:2006-10.
30. Harizman N, Oliveira C, Chiang A, Tello C, Marmor M, Ritch
12. Kotowski J, Wollstein G, Folio LS, Ishikawa H, Schuman JS. R, et al. The ISNT rule and differentiation of normal from
Clinical Use of OCT in Assessing Glaucoma Progression. glaucomatous eyes. Archives of ophthalmology (Chicago, Ill :
Ophthalmic surgery, lasers & imaging : the official journal of the 1960) 2006;124:1579-83.
International Society for Imaging in the Eye 2011;42:S6-S14. 31. Bowd C, Weinreb RN, Williams JM, Zangwill LM. The retinal
nerve fiber layer thickness in ocular hypertensive, normal,
13. Zangwill LM, Bowd C, Berry CC, Williams J, Blumenthal EZ, and glaucomatous eyes with optical coherence tomography.
Sanchez-Galeana CA, et al. Discriminating between normal and Archives of Ophthalmology 2000;118:22-6.
glaucomatous eyes using the Heidelberg Retina Tomograph, 32. Kanamori A, Nakamura M, Matsui N, Nagai A, Nakanishi
GDx Nerve Fiber Analyzer, and Optical Coherence Tomograph. Y, Kusuhara S, et al. Optical coherence tomography detects
Archives of ophthalmology (Chicago, Ill : 1960) 2001;119:985-93. characteristic retinal nerve fiber layer thickness corresponding to
band atrophy of the optic discs. Ophthalmology 2004;111:2278-
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on the thickness of the retinal nerve fiber layer measured 33. Schuman JS, Pedut-Kloizman T, Pakter H, Wang N, Guedes V,
by Cirrus HD optical coherence tomography. Investigative Huang L, et al. Optical Coherence Tomography and Histologic
ophthalmology & visual science 2010;51:4075-83. Measurements of Nerve Fiber Layer Thickness in Normal and
Glaucomatous Monkey Eyes. Investigative ophthalmology &
15. Malakar M, Askari SN, Ashraf H, Waris A, Ahuja A, Asghar visual science 2007;48:3645-54.
A.Optical coherence tomography assisted retinal nerve
fibre layer thickness profile in high myopia. J Clin Diagn Res Cite This Article as: Yadav N, Sahai A, Sharma R K, Shamshad MA,
2015;9:NC01-3. Gupta S, . Singhal Y. Reliability of OCT Assisted RNFL Thickness In
Diagnosing Glaucoma In High Myopia Delhi J Ophthalmol 2020 ; 31
16. M Mrugacz AB-L, D Sredzinska-Kita. . Use of optical coherence (2) :47-50.
tomography in myopia. J Pediatr Ophthalmol Strabismus
2004;41:159-62. Acknowledgments: Nil

17. Zha Y, Zhuang J, Lin D, Feng W, Zheng H, Cai J. Evaluation Conflict of interest: Nil
of myopia on retinal nerve fiber layer thickness measured by
Spectralis optical coherence tomography. Experimental and Source of Funding: None
Therapeutic Medicine 2017;14:2716-20.
Date of Submission: 11 Mar 2019
18. Schweitzer KD, Ehmann D, García R. Nerve fibre layer changes Date of Acceptance: 17 May 2020
in highly myopic eyes by optical coherence tomography.
Canadian Journal of Ophthalmology 2009;44:e13-e6. Address for correspondence

19. Kamath A, Dudeja L. Peri-papillary retinal nerve fiber layer Neha Yadav M.B.B.S
thickness profile in subjects with myopia measured using optical
coherence tomography. Journal of Clinical Ophthalmology and Address: Sahai hospital and research
Research 2014;2(3):131-6. centre,SP-15 Bhabha Marg, Moti Dungri,
Jaipur, Rajasthan, India
20. Singh D, S KM, Agarwal E, Sharma R, Bhartiya S, Dada T. E-mail address: [email protected]
Assessment of Retinal Nerve Fiber Layer Changes by Cirrus
High-definition Optical Coherence Tomography in Myopia. Quick Response Code
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Bahmani-Kashkouli, Mostafa Soltan-Sanjari. Optical Coherence
Tomography-Measured Nerve Fiber Layer and Macular
Thickness in Emmetropic, High-Myopic and High-Hyperopic
Eyes Iranian Journal of Ophthalmology 2008;20:4-9.

22. Sowmya V, Venkataramanan VR, Prasad V. Effect of Refractive
Status and Axial Length on Peripapillary Retinal Nerve Fibre
Layer Thickness: An Analysis Using 3D OCT. J Clin Diagn Res
2015;9:NC01-4.

23. Garcia-Valenzuela E, Anderson NG, Pons M, Iezzi R. Retinal
Thickness by OCT in Subjects With Emmetropia, Hyperopia
and Myopia. Investigative ophthalmology & visual science
2002;43:2574.

24. Savini G, Barboni P, Parisi V, Carbonelli M. The influence of
axial length on retinal nerve fibre layer thickness and optic-disc
size measurements by spectral-domain OCT. Br J Ophthalmol
2012;96:57-61.

25. Wang G, Qiu KL, Lu XH, Sun LX, Liao XJ, Chen HL, et al. The
effect of myopia on retinal nerve fibre layer measurement:
a comparative study of spectral-domain optical coherence

E-ISSN: 2454-2784  P-ISSN: 0972-0200 50 www.djo.org.in

DJO Vol. 31, No. 2, October-December 2020

Original Article

Bandage Contact Lens: a boon for corneal ulcer cases

Abstract Rashmi Kewaliya Joshi, Surbhi Kanawa, Anju Kochar

S.P. Medical College, PBM Hospital Bikaner Rajasthan, India.

Purpose: Bandage contact lenses are fabricated hydrogel lenses, effective in many corneal problems, most commonly
in the healing of incisions occurring after refractive surgery and traumatic corneal abrasions. They promote healing,
improve vision and act as a delivery mechanism for drugs. The principle therapeutic aim of these lenses is to provide
relief from pain, provide mechanical protection and seal corneal perforations by acting as a splint for the underlying
weaker tissue. This study was planned to evaluate therapeutic efficacy of bandage contact lenses in cases of non
healing corneal ulcer, impending perforation and perforated corneal ulcer cases.

Methods: It was a single centre prospective study. 65 corneal ulcer cases were selected in whom BCL was applied from
1 week to 3 months. Cases were divided in 2 groups; Group A, with descemetocele or small corneal perforation, in
whom BCL was applied at 1st day and group B with non- healing corneal ulcer cases, in whom BCL was applied after
20-30 days.

Results: Out of 65 patients 36 were males and 29 were females. Group A had 34 cases and Group B had 31 cases. The
healing time of corneal ulcer was 12.80±6.48 days in group A and 10.24±4.59 days in group B. No serious complication
was noted in any case. 85% cases reported visual recovery.

Conclusion: 90-97% relief was noted post BCL application without undue complications. Timely BCL application, broad
spectrum antibiotic and antifungal treatment and proper monitoring helped to salvage these eyes.

Delhi J Ophthalmol 2020;31;51-55; Doi http://dx.doi.org/10.7869/djo.591
Keywords : Bandage Contact Lens, Corneal Ulcer, Perforation

Introduction evaluate therapeutic efficacy of bandage contact lenses in
cases of non healing corneal ulcer, impending perforation
The burden of corneal ulcer cases is increasing at an and perforated corneal ulcer cases.
immense rate. They cause sight threatening complications
and are prevalent among all age groups. Corneal ulcer can Materials and Methods
be of bacterial, fungal, viral, or parasitic etiology. Sometimes
sterile corneal ulcers can occur secondary to loss of sensory It was a single centre prospective study conducted from
function. In medical therapy, antibiotics, antifungal, May 2016 to July 2019 at a tertiary care hospital. Out of
antiviral, mydriatics and sometimes steroids are used for 250 patients of corneal ulcer of varying etiology attending
their treatment.1 Many times, these cases respond poorly the department for treatment, 65 corneal ulcer cases were
to medical therapy due to a number of reasons like delayed selected in whom BCL was applied after obtaining written
presentation at tertiary centre, non compliance, environmental consent. The BCLs used in the study were soft hydrogel low
conditions etc. This may result in complications like severe water content lenses (<45%). In some, BCL was kept for 1wk
thinning, descemetocele, ectatic cicatrix or perforation. The and others up to 3 months based on patient compliance and
indications for surgical management are large ulcer with healing process. Before the commencement of the study,
risk of scleral involvement, extreme thinning or perforation, approval was sought and obtained from the Institutional
worsening in spite of treatment and uncertain etiology. Ethics Committee.
Different modalities used are tissue adhesives, bandage Before BCL application, a detailed clinical history and
contact lenses, lamellar or full thickness patch graft, thorough local examination was done. Routine blood
penetrating keratoplasty or conjunctival graft.2 Surgery has investigations including fasting blood sugar to rule out
its own complications such as inconvenience of observation, diabetes mellitus and test for HIV was performed to rule
higher cost and a larger psychological and economic burden. out immuno-compromised status of the patient. Treatment
Therefore some cheaper, convenient and feasible methods given to each patient was customized according to his local
like Bandage contact lenses are required for these cases. presentation and systemic status and also changed during
The Bandage contact lenses (BCLs) are effective in many the course as per need. As a part of routine protocol, corneal
corneal problems, most commonly used in the healing of scrapings were taken and sent for culture and sensitivity at
incisions occurring after refractive surgery and traumatic the time of presentation and again after a week in culture
corneal abrasions. They promote healing, improve vision positive cases.
and act as a delivery mechanism for drugs. In our study the BCL applied cases were divided in 2 groups
Contact lenses have undergone many modifications from first based on a number of factors:
corneal plastic lens to the introduction of present hydrogel Group A: Cases who presented with descemetocele or small
lens by Wichterle and Linn 1960.3 Bandage contact lenses perforation with absence of iris incarceration with the size of
are fabricated hydrogel lenses.4 This study was planned to perforation not exceeding 1 mm.

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DJO Vol. 31, No. 2, October-December 2020

Group B: Non- Healing corneal ulcer cases with corneal Table 1 : Demographic profile of patients in two groups.
thinning (not healed in 10-20 days). The size of ulcer in
these cases ranged from 3.5 to 6 mm in diameter, central or S. No. Group A Group B
para-central in location and up to half of the stromal layer in No. (%) No. (%)
depth with no scleral involvement. 1 Males
Trial fitting was done prior to BCL application as keratometry 2 Females 21(32) 15(23)
reading was not possible. First 4% xylocaine eye drop was 3 Mean Age
instilled in patient’s conjunctival sac and after 2 minutes 13(20) 16(25)
interval BCL was applied to the patient’s diseased cornea.
Lens fit was examined on slit lamp and patient was kept 45.20±20.71 41.62±15.54
under observation for minimum 3 hrs (to check proper
fitting and tolerance of the patient). Topical and systemic very small perforation with no iris tissue incarceration. In
medications were continued and eye ointments withdrawn. these cases also BCL was applied immediately after complete
The patients were instructed to report immediately if there is evaluation. Cyanoacrylate glue was not applied in any of
pain, foreign body sensation or fogginess of vision. these cases. Culture could not be sent for these cases as there
were chances of perforation. As per clinical presentation
Evaluation treatment was started in these cases. (Figure 1 and 2).

A proforma was prepared to thoroughly evaluate the Table 2 shows the etiological distribution of cases in group
patients for amelioration of signs and symptoms and for B. Maximum numbers of cases were of bacterial and fungal
any improvement in visual status. Slit lamp examination ulcer. BCL was applied in them since they showed poor
was performed on every follow up to evaluate corneal ulcer healing even after 20-30 days of continued treatment.
status and proper BCL alignment was noted. IPD patients Table 3 shows 20% of the patients in group A informed of
were reviewed on a daily basis till discharge and then as per
schedule. Outdoor based patients were followed up at day 1, Table 2 : Etiological distribution of cases in Group B
day 3, day 7 and then on weekly basis for 3 months.
S. No. Etiology of Corneal Ulcer in Group No. Of Cases (%)
Results B
1
A total of 65 corneal ulcer cases were taken in our study, in 2 Viral Corneal Ulcer 3 (9.6%)
which BCL was applied. Out of 65 patients, 36 were males 3
and 29 were females. We divided the patients in two groups. 4 Bacterial Corneal Ulcer 7 (22.5%)
The mean age of patients in group A was 45.20±20.71 and in 5
group B was 41.62±15. (Table 1) 6 Neuroparalytic Keratitis 1 (3.2%)
7
In GroupA, we had a total of 34 cases. 15 (44%) cases presented Marginal Corneal Ulcer 2 (6.5%)
with descemetocele on their first visit, BCL was applied to
them. 19 (56%) patients had marked corneal thinning or a Fungal Corneal Ulcer 7(22.5%)

Bacterial + Fungal Corneal Ulcer 5 (16.1%)

Negative culture report 6 (19.4%)

Total 31

Figure 1: Shows image of a case of corneal ulcer with descemetocele at the time of presentation in the left and image after 10 days of BCL application in the right.

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DJO Vol. 31, No. 2, October-December 2020

Figure 2: Shows images of a case of corneal ulcer who presented with para-central infiltrate with small perforation (left). BCL was applied to this case and showed
marked improvement within 7 days (right). Edge of Bandage contact lens is also clearly visible in the image to the right.

Table 3 : Improvement on Follow up in Group A Table 4 : Improvement on Follow up in Group B

Improvement on Follow up in BCL applied Cases (%)N=34 Improvement on Follow up in BCL applied Cases (%)N=31

S. Parameters 1st day 3rd Day 1wk 1 month S. Parameters 1st day 3rd Day 1wk 1month
No. No.

Symptoms Symptoms

1 Pain relieved 20% 60% 80% 97% 1 Pain relieved 20% 60% 80% 90%

2 Improvement in 10% 60% 82% 95%
Blepharospasm
2 Improvement in 3% 71% 87% 97%
Blepharospasm 94% 94% 94% 3 Foreign body 65% 85% 90% 92%
sensation
3 Foreign body 86% 42% 75% 85% Relieved
sensation
Relieved Signs

Signs 1 Vision Improved 6% 35% 65% 75%
1 Vision Improved 8%
2 Congestion 9% 52% 75% 90%
Decreased

2 Congestion 14% 52% 75% 94% 3 Decrease in ulcer 0% 30% 65% 85%
Decreased 3% 60% 83% 97% size

3 Decrease in pain on day 1st while 90% of the cases had pain relief by
ulcer size the end of the month. 95% cases showed improvement in
blepharospasm which was marked in few of these ulcer
pain relief on 1st day and about 97% of the patients reported cases earlier. Congestion decreased up to 90% and also ulcer
relief in pain by end of 1st month of BCL application. From size reduced in about 85% of these cases. However only 75%
all 34 cases 94% of cases showed relief from foreign body of cases showed improvement in vision, which could be
sensation by 3rd day itself. 97% of cases showed decreased attributed to large leucomatous corneal opacities.
ulcer size and 94 % showed decreased congestion by 1 The healing time of corneal ulcer was 12.80±6.48 days in
month of BCL application. Although improvement in vision group A compared with 10.24±4.59 days in the other group.
was only shown by 85% of cases it could be largely due to No serious complication was noted in any case in this study.
corneal opacification even after healing. (Figure 3). In group A two patients showed no improvement in this
Figure3.Shows series of images at day 1, day 7, after 1 month study and BCL was discontinued after 1month of application
and after 3 months of a case of non healing corneal ulcer because of intolerance to BCL. However in these 2 cases no
undergoing treatment along with BCL application. disease progression was noted.
(Table 4) shows that 20% cases in group B showed relief in

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DJO Vol. 31, No. 2, October-December 2020

Figure 3: Shows series of images at day 1, day 7, after 1 month and after 3 months of a case of non healing corneal ulcer undergoing treatment along with BCL
application.

Discussion later be released gradually over a prolonged period of time.12
In our study we have observed marked relief (90-97%) from
Bandage contact lenses are useful in various corneal diseases troublesome symptoms like pain, watering, blepharospasm
as they promote corneal healing, pain relief and better drug and foreign body sensation post BCL application.
delivery. They are also used in trichiasis, entropion and We observed healing of corneal perforation and ulcer with
traumatic corneal abrasions. BCLs have been shown to be acceptable visual results and no serious complications
useful in various other conditions like bullous keratopathy, after BCL application. Similar results were found in one
dry eye syndrome and filamentary keratitis.5, 6 case series on usage of BCL in perforated corneal injuries.13
In our study, we have exclusively used BCL in all spectrums Another study has shown that BCL is safe with no serious
of corneal ulcer cases. As most of the patients in our study complications after application and helps in better drug
came from rural areas, they mostly neglected the condition penetration of antibiotic eye drops.14
initially or took treatment from some quacks. Such patients Patients have also reported improvement in vision post
presented in late stages and came with small perforation or BCL application. Marked visual improvement was not
descemetocele or corneal thinning. BCL was immediately seen, which could be attributed to nebular and leucomatous
applied in them after complete evaluation to prevent further opacities of cornea or cataractous lens changes. We were
deterioration. As culture report could not be sent for these still able to salvage these cases from undergoing mutilating
patients, empirical treatment based on clinical assessment surgery like evisceration. Moreover there is a later hope of
was started along with BCL application. better visual recovery by penetrating keratoplasty surgery.
Thirty four of such cases (Group A) of corneal perforation and
descemetocele were included in our study, which showed Conclusion
marked improvement after BCL application. Similar results
with improvement of up to 80% are shown in various other This study shows that BCL is helpful in cases of
studies which reported healing by rapid epithelialization of descemetocele, small perforation and non healing corneal
ulcer after BCL use.7, 8 The mechanism by which BCL helps in ulcers. BCL application in these cases leads to 90-97% relief
healing of small perforation is multi-factorial which includes without undue complications. Timely BCL application,
mechanical protection, structural support and opposition of broad spectrum antibiotic, antifungal treatment and proper
wound margins.9 Corneal healing and re-epithelialization is monitoring helped to salvage these eyes. However further
promoted by BCL as a result of its protective action on new studies are required to establish its role in infective keratitis
epithelial cells which are otherwise repeatedly disturbed by cases and as an alternative to surgical management.
eyelid blinking and eye movements. BCL application for 4-7
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Cite This Article as: Joshi Rashmi, Kanawa Surbhi. Bandage
Contact Lens: a boon for corneal ulcer cases. Delhi J Ophthalmology.
2020 ; 31(2): 51-55

Acknowledgments: Nil

Conflict of interest: None declared

Source of Funding: None

Date of Submission: 13th March 2020
Date of Acceptance: 22nd May 2020

Address for correspondence

Surbhi Kanawa, Resident

Department of Ophthalmology
S.P. Medical College, PBM Hospital
Bikaner, Rajasthan, India.
Mailing Address: 61, Tagore Nagar,
Kartarpura, Jaipur, India,
Email: [email protected]

Quick Response Code

E-ISSN: 2454-2784  P-ISSN: 0972-0200 55 Delhi Journal of Ophthalmology

DJO Vol. 31, No. 2, October-December 2020

Original Article

Effect of Quantum of Energy used During Nd:YAG Laser
Posterior Capsulotomy on Magnitude of IOP Rise

Neha Verma, Ashish Ahuja

Department of Ophthalmology Sant Parmanand Hospital, Civil Lines, New Delhi, India.

Abstract Objective: To find out whether there exists a correlation between the quantum of energy used and the amount of rise of
intra ocular pressure (IOP) following Nd:YAG laser capsulotomy.

Materials and methods: The subjects were enrolled after taking a written informed consent. A total of 110 patients
undergoing Nd:YAG laser posterior capsulotomy for management of posterior capsule opacification with a minimum of 3
months following cataract surgery. After detailed history and ocular examination ,Nd:YAG laser capsulotomy was performed.
Pre-laser IOP was noted. Nd:YAG laser posterior capsulotomy was performed. Laser energy used was noted following which
post-laser IOP was recorded after 1, 2 and 4 hours post-procedure. Paired t-test was used for comparison of means of IOP
and energy levels. ROC analysis was used to predict the cutoff value of energy on the basis of change of IOP from baseline.

Results: Mean energy used in Nd:YAG Laser posterior capsulotomy procedure for all patients was 58.57±34.63 mJ. Mean IOP
at 1st hour follow-up was 15.32±2.91 mmHg, at 2nd hour follow-up was 16.24±3.23 mmHg and at 4th hour follow-up was
16.18±3.35 mmHg. At all three follow-ups, mean change in IOP was found to be statistically significant (p<0.001).

Conclusion: Post laser IOP rise is minimal and transient; it varies with the amount of energy used.


Delhi J Ophthalmol 2020;31;56-61; Doi http://dx.doi.org/10.7869/djo.592

Keywords: Intra Ocular Pressure (IOP), Posterior Capsular Opacification (PCO), Laser Capsulotomy.

Introduction anti-glaucoma drugs and a closer follow-up and avoid
any inadvertent usage of anti-glaucoma drugs in all
Cataract is the major cause of blindness in India accounting pseudophakes undergoing laser capsulotomy.
for about 62.6% amongst all causes of blindness.1 Cataract
surgery is probably the most common Ophthalmic surgical Materials and methods
procedure being carried out throughout the world. Posterior
capsular opacification is a frequent complication of cataract This being a prospective observational study, carried out
surgery. It varies from 7% to 31% ,2 years post cataract surgery.
Although the incidence of PCO varies among studies, rates at the Department of Ophthalmology, Sant Parmanand
as high as 11.8% at 1 year after cataract surgery, 20.7% at 3
years, and 28.4% at 5 years have been reported.2 Neodymium Hospital, New Delhi, and involved 110 pseudophakic eyes
Yttrium Aluminum Garnet (Nd:YAG) laser capsulotomy
is a safe, non–invasive and time-trusted procedure for the with PCO following cataract surgery studied over a 12
management of PCO.[1] PCO occurring within 3 mm of the
central posterior capsule affects visual acuity significantly.3 month period after taking a written informed consent from
Since 1980, Nd:YAG laser capsulotomy has become a standard
treatment to improve visual acuity in pseudophakic patients the patients and approval from the ethical committee.
with PCO.4,5, Improvement in visual acuity after Nd:YAG
laser capsulotomy in patients with significant PCO has been Inclusion criteria
well documented.6,7,8 Improvements in glare and contrast
sensitivity may also be important outcome measures for Pseudophakic eye with visual impairment due to significant
many patients.9,10,11 Although Nd:YAG laser capsulotomy is
accepted as standard treatment for PCO and has been found PCO following a minimum of three months of uneventful
to be safe and effective, it is not without complications, some
of which can be sight-threatening such as retinal edema and cataract surgery, with no other complications were included
detachment.12
It is important to evaluate anterior and posterior chamber in the study. Exclusion criteria
parameters before and after Nd:YAG laser capsulotomy
because it can cause complications, like elevation of • Patients with glaucoma or any anti-glaucoma
intraocular pressure (IOP) and corneal injury.13,14,15 In our medications
study we tried to evaluate the correlation between quantum
of energy used during Nd:YAG laser capsulotomy for • Cases with postoperative complications like
PCO after cataract surgery with an objective to find out if endophthalmitis.
there exists a correlation between the two,which would
help us determine those patients who require prophylactic • Any active ocular inflammation
• Posterior capsular opacification in aphakic eyes.
• Undergone any anterior segment LASER procedure or

any intraocular surgery other than cataract surgery
• Uncooperative patients, e.g. patient with mental

retardation, neurological problems.
• Having baseline (prelaser) IOP ≥22 mm of Hg,
• Patients having any corneal abnormality or physical/

mental limitation .
A total of 110 consecutive patients were recruited in this
study. An evaluation of the patients requiring Nd:YAG
laser capsulotomy was carried out prior to the procedure.

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DJO Vol. 31, No. 2, October-December 2020

Amount of total laser energy used was recorded. Intraocular Table 1: Demographic and Pre-operative findings for all patients
pressure was recorded.
After a thorough history and ocular examination including Variables Mean ±SD
visual acuity, slit lamp biomicroscopy, fundus and 83±8.14
applanation tonometry, Nd:YAG laser capsulotomy was Age (in years) All patients (n=110) 56.11±7.82
carried out by using a Zeiss laser model VISULAS II PLUS. 57.75±8.54
Only one eye underwent the procedure on one day. In case Male 2.68±1.34
the capsulotomy was required in both the eyes, the second
eye was undertaken independently and was recruited in the Female 0.539±0.24
study to avoid any confounding factors related to the subject.
Dilatation of the pupil was carried out using Tropicamide Time difference between cataract surgery and 14.52±2.86
1%. The procedure was carried out after anaesthetizing current procedure (years)
the eye with topical proparacaine hydrochloride 0.5%,
while a capsulotomy size of 3 mm or more was considered Pre-capsulotomy Best Corrected Visual acuity
adequate. Post-laser all patients were prescribed (LogMAR)
Loteprednol etabonate 0.5% eye drops 4 times a day along
with Carboxymethylcellulose sodium 0.5% lubricating eye Pre-capsulotomy Intraocular Pressure (mmHg)
drops 4 times a day, beginning immediately after laser and 14.52±2.86
for one week. The post laser IOP was recorded by Goldmann
Applanation Tonometer at 1hour, 2 hours and 4 hours. Table 2: No. of patients with IOP elevation after laser capsulotomy
according to time interval
Case Definitions
IOP changes Post Nd:YAG laser capsulotomy
• Mild rise of IOP: Any elevation of IOP less than (mmHg)
5 mm of Hg above the baseline pre laser IOP. For No. of patients No.of patients No. of
all considerations including data analysis, this was patients
clubbed with no rise of IOP. (n=110) (n=110) (n=110)
after 4 hour
• Moderate Rise of IOP: A rise of ≥5 mm of Hg above the after 1 hour after 2 hour
baseline pre laser IOP
No rise 20 (18.2) 10 (9.1) 13 (11.8)
• Severe Rise of IOP: A rise of ≥10 mm of Hg above the
baseline pre laser IOP 1-5 77 (79.1) 76 (79.0) 77 (79.1)

The data was analyzed using Statistical Package for Social 6-10 3 (2.7) 14 (11.9) 10 (9.1)
Sciences, version 23.0. All data were reported as averages
and standard deviations. Independent samples or paired‘t’- >10 0 (0.0) 0 (0.0) 0 (0.0)
test and ANOVA was used to compare before and after
capsulotomy data. ROC analysis was used to predict the Table 3: Mean IOP elevation with respect to time interval after
cutoff values of energy with respect to IOP change (from Nd:YAG laser capsulotomy
baseline to follow- up). A “p” value less than 0.05 was
considered to be statistically significant. Time Interval Intraocular Mean change P value
pressure (IOP) from baseline (paired
Results Mean±SD sample t
(mmHg) test)
The mean age of the study sample was found to be 56.83±8.14
years (ranging from 42-75 years), implying that the majority Pre capsulotomy 14.52±2.86 - -
of patients were in their 60s. Males being 62 (56.4%) followed
by females 48 (43.6%) with male to female ratio as 1.29:1. The Post At 1 15.32±2.91 0.80±2.29 <0.001
mean time difference between cataract surgery and current capsulotomy hour 16.24±3.23 1.72±2.90 <0.001
procedure was 2.68±1.34 years. The mean baseline (Pre-
capsulotomy), BCVA value was 0.539±0.242 LogMAR and At 2
mean intraocular pressure value was 14.52±2.86 mm Hg. hour
[Table No. 1] The elevation in IOP was recorded at 1 hour, 2
hour, and 4 hour following Nd:YAG laser capsulotomy and At 4 16.18±3.35 1.66±3.04 <0.001
it was mostly found that patients showed 1-5mmHg rise in hour
IOP. [Table No. 2] Mean IOP elevation with respect to time
Iinterval after laser capsulotomy measured at 1 hour, Table 4: Association between amount of energy used and rise in
2 hour and 4 hour was found to be highly statistically IOP at different follow up intervals after Nd:YAG Laser Posterior
significant (p<0.001). [Table No. 3]The association between
amount of energy used and rise in IOP at different follow- Capsulotomy
up intervals after Nd:YAG Laser Posterior Capsulotomy
was also found to be statistically significant (p<0.05). Energy Level <40 mJ 40-80 mJ >80 mJ ‘p’
Groups (n=40) (n=46) (n=24) value
(Anova
Energy level Mean±SD Mean±SD Mean±SD Test)
used (mJ) <0.001
27.87 58.70 110.46
Baseline IOP ± ± ± 0.162
values (mmHg) 7.08 11.84 29.59

14.13±2.55 15.13±3.38 14.0±2.02

Post 1 0.40±2.06 0.58±2.58 0.30±2.04 0.010
procedure hour 0.50±2.54 1.30±2.76 1.17±3.05 <0.001
rise in 2.04±1.73 4.42±1.89 4.88±1.99 <0.001
IOP at 2
hour

4
hour

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DJO Vol. 31, No. 2, October-December 2020

[Table No. 4] A positive significant correlation between optimal cutoff point of energy at 1 hour, 2 hour and 4 hour
change in IOP following posterior capsulotomy and after procedure was 58.50, 65.0 and 71.0 respectively for
total energy use was observed. The magnitude of this IOP rise from baseline. It was observed that YAG energy
correlation was mild at 1 hour (r=0.35) and moderate at determination 4 hours after procedure has high accuracy for
2 hour (r=0.553) and 4 hour (0.633) intervals (Figure 1). prediction of IOP rise. (Demonstrated in graphs ROC 1, 2 &
3)
Receiver operating (Table No.5) characteristic (ROC) analysis
was used to predict the cutoff value of energy on the basis of Discussion
their IOP change from baseline. For ≥5 mm of Hg IOP from
baseline, Area under curve (AUC) of energy at 1 hour, 2 Posterior Capsular Opacification (PCO) causes glare, impairs
hour and 4 hour after Nd:YAG Laser Posterior Capsulotomy contrast sensitivity and remains a major concern of decreased
procedure was 0.655, 0.802 and 0.918, respectively. The vision after cataract surgery. The use of Nd:YAG laser has
definitely simplified the treatment of posterior capsular
opacification. It being an entirely non-invasive technique,
has become popular for doing posterior capsulotomy
and has been established as a standard treatment for PCO
replacing surgical capsulotomy.16 Nd: YAG laser breaks
the posterior capsule following a pressure wave created by
infrared light of 1064 nm which is amplified and focused so
that electrons are ripped away from nuclei to form energy
plasma and corresponding shock wave. In our study of 110
cases, majority of the patients were males 62 (56.4%), mostly
above 50 years of age; it was the also commonest age
group that underwent cataract surgery. A similar trend was
noted by Shetty NK and Sridhar N et al
who depicted 60% males and 40.0% females and 68.6% of the
studied patients were in the age group ranging 50-70 years.
Kaur P et al and HavaleNG et al17 also reported a higher
proportion of males over females in their respective studies.
However, gender difference does not indicate any gender

Table 5: ROC analysis showed that the optimal cutoff values of energy for all follow up

Positivea(Valid N) ROC 1 ROC 2 IOP0- ROC 3 Larger values of the test result variable(s)
Negative (Valid N) IOP0-IOP1 IOP2 IOP0- indicate stronger evidence for a positive actual
IOP4 state.
Area 8 20 20 a. The positive actual state is ≥ 5
Std. Errora 102 The test result variable(s): energy has at least one
90 90 tie between the positive actual state group and
Asymptotic Sig--b 0.655 the negative actual state group. Statistics may be
0.097 0.802 0.918 biased.
Asymptotic Lower 0.145 0.059 0.026
95% Bound 0.465 0.000 0.000 a. Under the nonparametric assumption
Confidence 0.686 0.866
Interval Upper 0.845 b. Null hypothesis: true area = 0.5
Bound 0.919 0.969
58.50
Cutoffa 65.0 71.0 The test result variable(s): energy has at least one
75.0 tie between the positive actual state group and
Sensitivity 64.7 73.3 the negative actual state group
65.50 80.2
Specificity 80.0 95.0 a. The smallest cutoff value is the minimum
Accuracy observed test value minus 1, and the largest

85.6 cutoff value is the maximum observed test
91.8 value plus 1. All the other cutoff values are the

averages of two consecutive ordered observed
test values.

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DJO Vol. 31, No. 2, October-December 2020

Graph 1: ROC 1 (IOP0-IOP1): Change in IOP from baseline to 1st hour post fondness neither for cataract surgery nor for PCO.
Nd:YAG capsuloto The mean age of the studied patients was found to be
56.83±8.14 years,similar to Bhargava R et al18 where mean age
Graph 2: ROC 2 (IOP0-IOP2): Change in IOP from baseline to 2nd hour post was 55.6±8.7 years. The mean time elapsed between cataract
Nd:YAG capsulotomy surgery and laser capsulotomy procedure was reported as
2.68±1.34 years, similar to Khanzada MAet al19 where mean
Graph 3: ROC 3 (IOP0-IOP4): Change in IOP from baseline to 4 hour post period was 2.5 years, and BhargavaR et alreported this period
Nd:YAG capsulotomy to be 22.9 months. PCO development rates vary at different
post-cataract surgery durations and the mean duration after
cataract surgery might generally ranges from 2 to 3 years.
In our study, 81.8% patients showed transient rise in IOP
after 1 hour of procedure whereas after 2 hours it was 91.9%
and after 4 hour of the procedure it was 88.2% .(None of
our study patients required any anti-glaucoma medication).
Similar to Flohr et al20 and Mohammed YK et al,21 they found
IOP elevation in >75% and 84% of cases respectively in
their studies. In Kaur P et al[16] study only 62.47% patients
showed transient rise in IOP after procedure. In this study,
mean IOP at 1st hour follow up was 15.32±2.91 mmHg, at
2nd hour follow up it was 16.24±3.23 mmHg and at 4th hour
follow up, it was 16.18±3.35 mmHg, thus showing a mean
increase of 0.80±2.29, 1.72±2.90 and 1.66±3.04 mmHg from
baseline respectively. At all three follow ups mean change in
IOP was found to be statistically significant (p<0.001.Similar
trend was reported by Richter CU et al.22 This relatively lower
rise in present study could be attributed to reduced levels of
energy used . In another study, it was observed that there was
statistically significant increase in IOP at 1 and 4 hour post-
laser when higher energy was used23 In Barnes et al24 study
the change in IOP was also relatively lower. Compared to
this in the present study during entire evaluation period, the
rise of >5 mm Hg was seen to be maximum at 2 hours when
18.2% patients showed a rise of >5 mm Hg. In the present
study >10 mm rise was observed in only 1 (0.9%) case at 4
hour interval. When topical hypotensives are used the rise
in IOP could also be reduced. In a study by Singh M et al25
the rise of IOP from baseline to 1 hour, 3 hour, 5 hour and 24
hours post-procedure was not found to be significant in the
groups receiving ocular hypotensive drug. Shetty NK and
Sridhar N et al reported that almost all the patients had a rise
in IOP 2 hours post-procedure. Hence IOP documentation
of IOP 2 hours post-procedure was observed to be more
predictive of persistent IOP rise compared to immediate
post-procedure IOP. In our study, the duration of IOP
elevation study was only upto 4 hour post-operative interval
and the reason for limiting this assessment only upto 4 hour
interval was because we had used a limited range of laser
energy only.
In our study, the mean energy required for Nd:YAG laser
posterior capsulotomy was 58.57±34.63 mJ. Patil MS et al
observed almost similar findings and they reported mean
energy used as 62.47 ± 33.65 mJ. In our study, patients
were divided into three groups, in maximum number of
cases 46 (41.8%) 40 to 80 mJ was used with a mean energy
58.70±11.84mJ and in 24 (21.8%) patients >80 mJ energy was
used with mean 110.46±29.59mJ and in rest <40 mJ energy
with a lowest mean energy 27.87±7.08 mJ used highly
significant (p<0.01). In a study by Waseem M et al,26 the low
energy group was exposed to laser energies below 50 mJ

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DJO Vol. 31, No. 2, October-December 2020

with a mean energy of 36.46±6.42 mJ and the high energy We recommend further studies with larger sample size and
group had IOP above 50mmHg with a mean of 56.84±2.65 variable energy use with same follow up intervals as used in
mJ. In their study they found rise of about 5.51±1.58 mmHg present study to explore this relationship further.
in the high energy group and 3.83±1.84 in the low energy
groups. References
Similar results were reported by Ari S et al27 as 58±18 mJ and
117±36 mJ respectively energy was used among two groups 1 Shetty N K, Sridhar S, Study of Variation in Intraocular Pressure
of patients receiving 14 to 80 mJ and 84 to 200 mJ of energy Spike (IOP) Following Nd- YAG Laser Capsulotomy. Journal of
respectively in their study. In Kaur P et al also used similar Clinical and Diagnostic Research. 2016 Dec, Vol-10(12): NC09-
mean energy levels among two study groups (38.01±9.34mJ NC12
and 62.46± 10.07 mJ.
In the present study, the relation between the amount of 2 Schaumberg DA, Dana MR, Christen WG, Glynn RJ. A systematic
energy used and rise in IOP at different intervals of follow overview of the incidence of posterior capsule opacification.
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We observed statistically significant association between a problem reduced but not yet eradicated. Arch Ophthalmol
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study showed that frequency of ‘raised IOP’ was associated
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be expected to be greater in patients who receive excessive Exp Eye Res 2009;88:257-69.
amount of YAG laser energy. Our results correspond with
Kaur P et al study results as pre-laser mean IOP was 14.45 5 Hu CY, Woung LC, Wang MC. Change in the area of laser
+ 2.52 mmHg which raised to 16.08+3.69 mmHg at 1 hour posterior capsulotomy: 3 month follow-up. J Cataract Refract
and peaked to 16.83+3.69 mmHg by 2 hour after laser Surg 2001;27:537-42.
capsulotomy procedure. Similarly, Ge J et al28 and Dawood
Z et al29 concluded transient IOP rise within 1.5-4hour and 6 Gardner KM, Straatsma BR, Pettit TH.Neodymium:YAG laser
1-3 hour after laser capsulotomy procedure respectively in posterior capsulotomy: the first 100 cases at UCLA. Ophthalmic
their study. Higher energy was required for higher grades Surg. 1985 Jan;16(1):24-8. PMID: 3838376
of PCO.Our study patients presented with both fibrous and
pearl types of PCO. However, our study did not compare 7 Stark WJ, Worthen D, Holladay JT, Murray G. Neodymium:YAG
the energy requirement with the grade of PCO. The possible lasers. An FDA report.Ophthalmology. 1985 Feb;92(2):209-12.
mechanisms for an increase in IOP could be: more the PMID: 3982799
energy used during the procedure, more particles were
liberated from posterior capsular breakdown, thus clogging 8 Wasserman EL, Axt JC, Sheets JH. Neodymium:YAG laser
of angle of anterior chamber and subsequently increasing posterior capsulotomy. J Am Intraocul Implant Soc. 1985
the IOP. Additionally, the acoustic shock waves release May;11(3):245-8. PMID: 4008310
inflammatory mediators that alter the trabecular meshwork
and the aqueous dynamics causing IOP rise. 9 Magno BV, Datiles MB, Lasa MS, Fajardo MR, Caruso RC,
Kaiser- Kupfer MI. Evaluation of visualfunction following
Conclusion neodymium:YAG laser posterior capsulotomy. Ophthalmology.
1997 Aug;104(8):1287-93. PMID: 9261315
Raised IOP is a frequent complication of Nd:YAG laser
posterior capsulotomy .It is dependent upon the amount 10 Sunderraj P, Villada JR, Joyce PW, Watson A. Glare testing in
of laser energy delivered to the eye during the procedure. pseudophakes with posterior capsule opacification. Eye (Lond).
The higher the energy used, the greater the rise in IOP .(Our 1992;6 ( Pt 4):411-3. PMID: 1478316
study did not compare the rise of IOP with the number of
shots used for performing the procedure) 11 Tan JC, Spalton DJ, Arden GB. The effect of neodymium: YAG
Hence, it is recommended that each patient undergoing Nd: capsulotomy on contrast sensitivity and the evaluation of methods
YAG laser posterior capsulotomy should receive minimum for its assessment. Ophthalmology. 1999 Apr;106(4):703-9. PMID:
possible laser energy and should be followed up for raised 10201590
IOP. Also limiting the use of amount of energy levels (< 50
mJ/ sitting) during Nd:Yag laser procedures can prevent post 12 Keates RH, Steinert RF, Puliafito CA, Maxwell SK. Long-term
laser IOP spikes. This will prevent unnecessary use of anti- follow-up of Nd:YAG laser posterior capsulotomy. J Am Intraocul
glaucoma drugs in most patients. Implant Soc. 1984 Spring;10(2):164-8. PMID: 6547424

Recommendations 13 MacEwen CJ, Dutton GN. Neodymium-YAG laser in the
management of posterior capsular opacification: complications
It was difficult to compare different studies due to different and current trends. Trans OphthalmolSoc U K 1986;105(Pt 3):337-
techniques of cataract surgery and different intraocular lens 44.
implant materials, their designs and the thickness of PCO.
14 Hu CY, Woung LC, Wang MC, Jian JH. Influence of laser
posterior capsulotomy on anterior chamber depth, refraction, and
intraocular pressure. J Cataract Refract Surg 2000;26:1183-9.

15 Aslam TM, Devlin H, Dhillon B. Use of Nd:YAG laser capsulotomy.
SurvOphthalmol 2003;48:594-612.

16. Kaur P, Gusain P, Mohan C, Bedi J. Effect of Nd: YAG laser
capsulotomy on IOP rise and its variation with energy used. Ind J
ClinExpOphthalmol. 2018;4(3):396-400.

17 Havale NG, Moitra M, Saxena D. A study of sociodemographic
profile of patients undergoing cataract surgery in New Civil
Hospital, Surat. International Journal of Medical Science and
Public Health 2016;5(6):1163-1166.

18. Bhargava R, Kumar P, Phogat H, Chaudhary KP. Neodymium-
yttrium aluminium garnet laser capsulotomy energy levels for
posterior capsule opacification. J Ophthalmic Vis Res 2015;10:37-
42.

19. Khanzada MA. Is the Nd:YAG Laser a safe procedure for posterior
capsulotomy?. Pak J Ophthalmol 2008;24(2):73-78.

20 .Flohr MJ, Robin AL, Kelley JS. Early complications following
Q-switched Neodymium: YAG laser posterior capsulotomy.
Ophthalomology. 1985;92(3):360-363.

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DJO Vol. 31, No. 2, October-December 2020

21. Mohammad YK, Jan S, Mohammad NK, Khan S, Kundi N. Visual Cite This Article as: Neha Verma, Ashish Ahuja. Effect of
outcome after Nd: YAG capsulotomy in posterior capsular Quantum of Energy used during Nd:YAG Laser Posterior
opacification. Pak J Ophthalmol. 2006;22(2):87-91 Capsulotomy on Magnitude of IOP Rise. Delhi J Ophthalmology.
2020;31(2):56-61
22. Richter CU, Arzeno G, Pappas HR, Steinert RF, Puliafito C, Epstein Acknowledgments: Nil
DL. Intraocular pressure elevation following Nd:YAG laser Conflict of interest: None declared
posterior capsulotomy. Ophthalmology.1985; 92:636-640. Source of Funding: None
Date of Submission: 30th Aug 2019
23 Patil MS , Balwir DN and Vidhate S. A Study of Nd:YAG Date of acceptance: 22nd May 2020
Laser Capsulotomy in the Management of Posterior Capsular
Opacification. MVP Journal of Medical Sciences. 2016;Vol 3(1):18- Address for correspondence
24 Neha Verma, MBBS, D.O.M.S, DNB

24. Barnes EA, Murdoch IE,Subramaniam S, Cahill A, Kehoe Department of Ophthalmology
B, Behrend M. Neodymium:yttrium- aluminium –garnet Sant Parmanand Hospital, New Delhi.
capsulotomy and intraocular pressure in pseudophakics patients Email : [email protected]
in glaucoma . Ophthalmology.2004;111(7):1393-7.
Quick Response Code
25. Singh M. Anterior Segment Nd:YAG Laser Procedures: to Study
intraocular pressure spikes and their prevention. Delhi Journal of
Ophthalmology. 2015;26(2):2454–784.

26. Waseem M, Khan HA. Association of Raised Intraocular
Pressure and its Correlation to the Energy Used With Raised
Versus Normal Intraocular Pressure Following Nd: YAG Laser
Posterior Capsulotomy in Pseudophakes. Journal of the College
of Physicians and Surgeons Pakistan 2010, Vol. 20 (8): 524-527

27 S. Ari, A. K. Cingü, A. Sahin, Y. Çinar, and I. Çaça, “The effects
of Nd : YAG laser posterior capsulotomy on macular thickness,
intraocular pressure, and visual acuity,” Ophthalmic Surg Lasers
Imaging, vol. 43, pp. 395–400, 2012.

28. Ge J, Wand M, Chiang R et al. Long term effect of Nd:YAG laser
posterior capsulotomy on intraocular pressure. Arch Ophthalmol.
2000;118(10):1334-1337

29. Dawood Z, Mirza SA, Qadeer A. Review of 560 cases of YAG laser
capsulotomy. J LiaquatUniv Med Health Sci. 2007;6(1):3-7.

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DJO Vol. 31, No. 2, October-December 2020

Original Article

Role Of Social Media As A Catalyser For Ocular Injury:
A Case Study Of Calcuim Carbide Gun Use In India

Namrata Kabra, Smriti Gupta

Department of cornea, Shri Ganapati Netralaya, Jalna, Maharashtra, India.

Abstract Introduction: Social media allows social growth of the society but has both advantages and disadvantages. We came
across one such example where people are making calcium carbide guns after watching video, spreading through
social media to get rid of animals and birds from their field. This in turn leads to blinding injuries in eyes.

Purpose: To highlight this novel mode of eye injury and to create awareness among people to stop use of such
dangerous calcium carbide guns that is leading to serious ocular injuries.

Material and method: A prospective study of all cases of calcium carbide related ocular trauma reporting to our
outpatient department (OPD). The demographic profile, severity of ocular injuries and management of cases were
recorded.

Result: We studied 14 eyes of 13 patients with variable degree of ocular injury sustained due to calcium carbide
exposure while mishandling calcium carbide gun. All of them were young males. Significant number of patients
(30.7%) had grade V injury according to Dua’s classification.

Conclusion: Video of making calcium carbide guns floating in social media leading to serious ocular injuries.
Awareness should be created among people to avoid making and using such dangerous weapons.

Delhi J Ophthalmol 2020;31;62-64; Doi http://dx.doi.org/10.7869/djo.593
Keywords: Social Media, Videos, Calcium Carbide, Ocular Injuries.

Introduction injury due to carbide exposure seen at tertiary eye care
centre from February 2020 to March 2020.
In this day and age, social media constantly surrounds us. It
has become a part of our generation’s lives. There are both Material And Method
positive and negative impacts of social media platforms. We
take misinformation seriously. Most users who generate This case series includes 14 eyes of 13 patients with a
misinformation do not share accurate information too, so it history of carbide exposure attending OPD from February
can be difficult to tease out the effect of misinformation it 2020 to March 2020. Complete history taking, slit lamp
self. Here by, we are presenting an interesting case series, examination, fundus examination with 90D lens and indirect
which shows the dangerous consequence of a video which is ophthalmoscopy were done. Ultrasound b scan was done
spreading through social media. when required. The classification of injuries was done by
Dua’s classification1.
Spread of such video showing some layman technique of
making calcium carbide (CaC2) gun at home, in order to get Table 1: Classification Of Injury According To Dua’s
rid of monkeys or birds from the field without highlighting Classification
its adverse effect leading to blinding or sight threatening
consequences in people’s life. Its parts are easily available GRADE I 1 7.6%
at the market at cheaper prices. People are making carbide
guns as shown in the video. When this gun did not work, GRADE II 2 15.3%
most of them tried to peep into the gun from the muzzle
side. The unfortunate delayed explosion of this gun causes GRADE III 3 23%
projection of calcium carbide particles leading to severe
ocular injuries. In few of the cases. after first firing, the GRADE IV 3 23%
residue gas got fired while gazing through the muzzle. In
one case, the gas exploded from the opposite end into the GRADE V 4 30.7%
eye instead of the muzzle.
Result
We reported 14 eyes of 13 patients of ocular injury with
variable extent of chemical, thermal and blast injury with All the patients were young male. Best corrected visualacuity
carbide gun giving similar history affecting either of the was ranging from perception of light to 6/18.
eyes. One patient had bilateral injury. We performed a Most common presentation was periocular skin burn with
prospective review of all patients who sustained ocular corneal burn with multiple foreign bodies in cornea with
variable degree of limbal and scleral ischemia as shown in
the (Figure 1 and 2).
Thorough eye wash was given to all the patients along with
removal of debris and calcium carbide particles from eyes

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DJO Vol. 31, No. 2, October-December 2020

Figure 1: Slit lamp photos (case 1-6) of carbide injury showing variable degree Figure 3: Intraoperative picture showing limbal and scleral ischemia with
of ocular burn. retained carbide particles and plaque in upper fornix.

Figure 2: slit lamp photos (case 7-9) showing variable degree of ocular burn. under local anaesthesia was done in 1 case. Two patients
Figure (9a) and (9b) showing bilateral grade 1 injury. refused for surgical intervention and 1 lost to follow up.
All patients were advised 1 weekly follow up and were
under topical anaesthesia. Treatment was given according found to be responding to the line of management on
to grade of injury. Oral and topical steroid was started along subsequent follow up visits. Though final visual acuity is
with topical antibiotic, lubricant, cycloplegic and oral vitamin yet to be determined in all the patients, we felt the urgency
C. Surgical intervention was required in 7 cases according of reporting of the emerging novel modality and sight
to grade of injury. Amniotic membrane transplantation threatening consequence which the ophthalmologist should
(AMT) under local anaesthesia was done in 3 cases. Figure be aware of, as social media can further bring a surge in
3 showing an intraoperative picture of a patient undergoing similar patients across the country. Around 12 plus videos
AMT. Amniotic membrane transplantation with tenoplasty are present in social media with a range of 500- 7 lacs views
with a with more than 39 lac views in total till date.

Discussion

Social media facilitates the sharing of ideas, thoughts, and
information through the building of virtual networks and
communities. The power of social media is the ability to
connect and share information with anyone on earth, with
many people simultaneously. But many times, social media
may be a conduit for misleading information, falsehood or
information without adequate warning for possible hazards.
We recently came across one such example.
The calcium carbide is one of the most commonly used
ripening agents for fruits inspite of being banned under
Food Safety and Standards regulations, 2011. CaC2 reacts
with water and produces acetylene gas also known as
calcium carbide gas. While its use is being discouraged due
to associated health hazards and carcinogenic properties,
people are finding new ways to use this cheap and easily
available chemical in the market. A video of making calcium
carbide guns using calcium carbide, plastic pipes, lighter
and water is getting viral in social media to get rid of animals

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DJO Vol. 31, No. 2, October-December 2020

and birds in the field. Inadvertent ignition of this chemical Cite This Article as: Namrata Kabra, Smriti Gupta Role of
can cause severe ocular injuries with unilateral or bilateral social media as a catalyser for ocular injury: A case study of
burn. Calcium carbide explodes when it comes in contact calcuim carbide gun use in India. DJO 2020;31(2):62-64
with water. This technique is used by people nowadays in Acknowledgments: Acknowledgment: Dr Vaibhav Patil for
their field. When this gun doesn’t work, people look inside technical support and support for video. Delhi J Ophthalmology.
the pipe to check. Delayed explosion of the chemical leads to 2020; 31(2):62-64
variable degree of ocular injury. Conflict of interest: None declared
Bandyopadhyay S2 et al reported 55 eyes of 33 patients Source of Funding: None
with calcium carbide injury during mango ripening season Date of Submission: 5th May 2020
in West Bengal, eastern India. Most common mode was Date of Acceptance: 20th May 2020
indigenous firework while playing, in children or igniting
evening lamps by house wives causing permanent visual Address for correspondence
disability. While the majority of patients in their study were Namrata Kabra MS
children and females, in our study, all of them were young
male. Consultant and Head, Department of
Testud et al3 in 2002 reported a case of calcium carbide ocular cornea, Shri Ganapati Netralaya, Jalna,
burn in an amateur speleologist. Maharashtra
To the best of our knowledge, as per medline and literature Email: [email protected]
search there is no case report regarding the homemade
calcium carbide guns, in the field, leading to eye injury. Quick Response Code
We immediately prepared a video regarding carbide gun
and ocular injuries and floated in social media. The link is as
follow: https://youtu.be/3EfhRl1BXK4

Conclusion

Effective surveillance to prevent use of banned substances
and restrict the easy availability of products with potential
for health hazards is needed. Any promotional videos on
social media should also include the precautions to avoid
health hazards if any and viewers of such videos should also
not follow the shared ideas blindly and be cautious and use
protective glasses during trying such ideas.
Conflicts of interest: No financial disclosures or conflict of
interest.

Reference

1. Dua HS, King AJ, Joseph A. A new classification of ocular surface
burns. Br J Ophthalmol 2001;85(11):1379-1383.

2. Bandyopadhyay S, Saha M, Biswas S, Ranjan A, Naskar AK,
Bandyopadhyay L. Calcium carbide related ocular injuries
during mango ripening season of West Bengal, eastern India.
Nepal J Ophthalmol 2013;5(10):242-245.

3. Testud F, Voegtle R, Nordmann JP, Descotes J. Severe ocular
burns by calcium carbide in a speleologist: a case report. J Fr
Ophthalmol 2002;25:308-311.

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DJO Vol. 31, No. 2, October-December 2020

Original Article

Comparison of Angiography Performance of Low-cost portable
Fundus camera with standard FFA camera – Validation Study

Deependra Vikram Singh, Gaurav Mathur, Rishi Bhardwaj, Ajay Sharma

Retina Department of Eye-Q Superspecialty Eye Hospitals, Sushant Lok, Gurugram, India.

Abstract Study Design: In an observational cross-sectional study, 91 eyes of 46 consecutive patients underwent simultaneous
Fundus Fluorescein Angiography (FFA) for common retinal disorders. The FFA images captured by both cameras were
graded by 3 Retinologists (DVS, GM, RB) in a structured format. 7 characteristics of FFA images that were used for
grading were Foveal Avascular Zone (FAZ) visualization, identifying branch retinal vein, Identification of any abnormal
hyper fluorescence at macula, Identification of Micro aneurysms, Identification of capillary non perfusion areas and
identification of leakage from retinal neovascularization, Image quality and Impact on Clinical decision. Results were
captured and statistically analyzed for interobserver and intercamera agreements.

Results: Out of total 7 features in FFA images graded by 3 Retinologists, 4 characteristics were found to have statistically
significant intercamera agreement for 3 retinologists. These were Identification of any abnormal hyper fluorescence at
macula, Identification of Micro aneurysms, Identification of capillary non perfusion areas and identification of leakage
from retinal neovascularization. These 4 characteristics also had very good agreement between 3 retinologists.

Conclusion: Based on this pilot study, we can conclude that the Fluorescein Angiography performance of this low-cost
portable Fundus camera for detecting clinically relevant findings was comparable to a standard Fundus camera. We
conclude that in resource limited settings, this low-cost portable Fundus camera can be a useful alternative to standard
Fundus camera for treating common retinal disorders..

Delhi J Ophthalmol 2020;31;65-70; Doi http://dx.doi.org/10.7869/djo.594

Keywords: Low-cost Fundus Fluorescein Angiography, Portable Fluorescein Angiography, Diabetic Retinopathy, Hyperfluorescence.

Introduction not been compared with standard Fundus camera. In an
observational cross-sectional study, we evaluated fluorescein
Globally, retinal diseases are a significant cause of visual angiography performance of low-cost portable Fundus
impairment and blindness. A recent metanalysis projected camera (Smartscope® Pro, Optomed Inc, Oulu, Finland)
that by 2020, Age-related macular degeneration (AMD) with standard fundus camera (Visucam® 500 by Carl Zeiss
and Diabetic Retinopathy will be responsible for moderate Inc., San Leandro, CA). FFA images from both cameras were
to severe vision loss in 8.8 million and 3.2 million cases compared and analyzed for quality and image parameters
respectively with 2.0 million people estimated to be blind by that are important in making clinical decisions for common
AMD.1 Prevalence of Diabetes2 and Diabetic retinopathy3 is retinal disorders.
increasing worldwide and global burden of macular diseases
is also increasing.4 Another systematic review estimated the Material and Methods
global prevalence of any retinal vein occlusion (RVO) in
people aged between 30 to 89 years and reported that 56.11 A single-site (tertiary eye care hospital, Gurugram India),
million people to be affected by any RVO.5 prospective, clinic-based comparative instrument validation
Asia is now home to approximately 80% of the world's study evaluated the FA performance of low-cost portable
diabetic population, including more than 60 million Indians, Fundus camera and compared it with standard fundus camera
and the total number of diabetic persons is expected to during a period of 6 months (January 2017 to June 2017). The
increase to more than 100 million by 2030.6 FA module of low-cost fundus camera (Smartscope® Pro,
India being a developing country where majority of Optomed Inc, Oulu, Finland) has camera sensor resolution
population lives in rural area, impact of retinal disorders can of 5 megapixels and clicks images with field of view of 40
be far higher and devastating due to constraints in manpower degrees. The standard camera (Visucam 500® Carl Zeiss
and infrastructure.7,8 Home eye care and Ambulatory Retina Inc., San Leandro, CA) used in this study has capture sensor
clinics can provide essential care to patients with retinal resolution of 5.0 mega pixels Charged Coupled Device
disorders in this low resource settings. A low-cost Fundus (CCD) with 2 fields of view 45° and 30° available. All images
camera for Fluorescein angiography seems to be a useful in this study were captured with 45° option only. Total
addition to this model. 91 eyes of 46 patients with Diabetic Retinopathy, retinal
While few low-cost portable imaging devices are now vascular occlusions or central serous retinopathy were
available for screening retinal diseases,9,10 A low-cost included. Eyes with neovascular AMD were not included
portable fundus fluorescein angiography (FFA) camera is because clinical utility of FFA has reduced for these cases.
not widely available. Eyes with hazy media due to cataract or posterior capsule
Fluorescein angiography performance of Low-cost opacification were excluded if treating surgeon felt that a
portable Fundus camera has not been evaluated and has good quality FFA images wouldn’t be obtained. All patients

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DJO Vol. 31, No. 2, October-December 2020

underwent simultaneous FFA on both low-cost Portable specialists attended a discussion session to align the
Fundus camera and standard Fundus camera. The study interpretation of different parameters to be graded that
was approved by institutional review board and adhered to included: FAZ visualization, identifying branch retinal
the tenets of the Declaration of Helsinki. Detailed Informed vein, Identification of any abnormal hyper fluorescence at
consent informing about nature of study was signed by all macula, Identification of Micro aneurysms, Identification of
subjects before the angiography procedures. The identity capillary non perfusion areas and identification of leakage
of all patients and the diagnosis of each image were from retinal neovascularization and Image quality.
masked before grading. Each patient underwent a detailed Table 1 shows the different Grading scales assigned to
ophthalmologic examination that included dilated fundus these parameters.
examination, color fundus photograph, and FFA using both Some of these features have already been described in earlier
fundus cameras. studies evaluating performance of FFA devices.12
FFA protocol Both sets of images (91 eyes from each camera) were graded
All patients were randomly assigned to one of the 2 groups by three senior retinal specialists experienced in assessment
– Z (Zeiss) group & O (Optomed) group. Patients in Z and management of retinal vascular disorders (D.V.S., G.M.,
group had early phase (First 1 minute) of FFA captured on R.B.).
standard (Zeiss) camera and subsequent mid phase captured As a protocol, for each ID, Images from Folder O were
on Slit-lamp mounted portable (Optomed) camera for next 2 graded first followed by images from Folder Z. The results of
minutes and finally late phases captured on both cameras. grading were captured in an excel sheet (Microsoft® Excel®
Reverse sequence was followed for patients in O group. All 2016 MSO. Version 2004) for statistical analysis.
FFA images were captured by experienced retinologists and
each eye got seven 45° photographs (ensuring that all ETDRS Statistical Analysis
fields are covered) captured. We stored all photographs
as Joint Photographic Experts Group (JPEG) files after Statistical analysis was performed using SPSS on-line
removing all patient Subscription – Version 23 (SPSS version 23; Statistical
Demographic details and assigning a unique ID number Package for Social Science, Chicago, IL). For each Grading
linked to the participant’s study ID number. Images from feature the statistical analysis was carried out to find out
low-cost Fundus camera (Optomed) were stored in native correlation and agreement between both devices.
state with JPEG quality of 1536 × 1156 pixels and those from Cohen’s Kappa analysis was also done for each feature to
Standard Fundus camera (Zeiss) were stored with JPEG test the agreement between 3 Retinologists for that feature
quality of 1064 × 1028 pixels. on each device. These analyses were carried out on an eye-
These Images were arranged in pairs with folders named specific basis. We used following interpretation for Kappa
by unique patient IDs by a trained technician who saved Analysis.13
Zeiss images and Optomed images of each eye in respective Poor agreement = Less than 0.20, Fair agreement = 0.20 to
folders. 0.40, Moderate agreement = 0.40 to 0.60, Good agreement =
Grading of Images 0.60 to 0.80, Very good agreement = 0.80 to 1.00.
Before grading was performed, all the participating retinal

Table 1: Grading scales for parameters used to evaluate FFA performance of both devices

S . Name of Parameter Scales used for Grading CD
No. AB

1 FAZ (percentage of FAZ visible) * 0 to 25% 26 to 50% 50 to 75% 75 to 100%

2 Branch Retinal Vessel Identification All 1st, 2nd & 3rd 1st & 2nd Order seen Only 1st order vessel
Order Vessels seen seen

3 Identification of any abnormal Yes No
hyper fluorescence at macula

4 Identification of MAs in areas of Yes No
leakage

5 Capillary Non perfusion Yes No

6 Leakages from RNV ** Yes No

7 Image Quality Excellent Image Moderate Image Poor Image Quality No Useful Image
(Only Disc and (Disc macula not
Quality (Details of All Quality (Good Image Macula seen) seen)

vessels seen and FAZ quality with loss of

seen clearly) details for small vessels

and capillaries)

Abbreviations: FFA, Fundus Fluorescein Angiography; FAZ, Foveal Avascular Zone; MA, Microaneurysms; RNV, Retinal Neovascularization.
* FAZ was evaluated in peak phase (25-30 seconds) for Camera which was used first and at 1 minute for the second Camera.
** Leakage from RNV was evaluated in late phase.

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DJO Vol. 31, No. 2, October-December 2020

Table 2: Descriptive Statistics of the sample (n=91 eyes of 46 subjects)

Categorical variables Frequency (column %)
Sex (n = 46 subjects)
15 (32.6%)
Female 31 (67.4%)
Male Diabetes status (n = 46 subjects)
14 (30.4%)
No DM 32 (69.6%)
DM Lens status* (n = 91 eyes)
54 (59.3%)
Phakic Clear 10 (11.0%)
Phakic Cataractous 27 (29.7%)
Primary Diagnosis** (n=46 subjects)
Pseudophakic

Diabetic Retinopathy 22 (47.8%)
Retinal Vein Occlusion 8 (17.4%)
9 (19.6%)
CSCR 5 (10.9%)
Retinal Vasculitis 2 (4.3%)

CRAO Mean (SE of Mean) Min, Max Median SD
Continuous variable 11.433
58.33 (1.686) 32, 82 60.50
Age (in years; n=46 subjects)

Abbreviations: DM. diabetes mellitus; IOL, intraocular lens; CSCR, Central Serous
Chorioretinopathy; CRAO, Central Retinal Artery Occlusion; SE, Standard Error; SD, Standard Deviation.
* Patients with advanced cataract or posterior capsule opacification that would hamper FFA interpretation were excluded.
** This was the primary diagnosis that was indication of performing FFA for any subject, so n=46

Table 3: Interobserver agreement between 3 retinologists (DVS, GM & RB) for different grading parameters

DVS Vs GM DVS Vs RB GM Vs RB

Grading Zeiss Optomed Zeiss Optomed Zeiss Optomed
Parameter p-value Kappa p-value
Kappa p-value Kappa p-value Kappa p-value Kappa p-value Kappa

FAZ (%age of 0.184 0.035 0.471 0.000 0.426 0.000 0.272 0.000 0.009 0.917 0.208 0.001
FAZ visible)

BRV NC* NC* NC* NC* 0.392 0.000 0.453 0.000
Identification

Abnormal 0.345 0.000 0.242 0.000 0.554 0.000 0.439 0.000 0.297 0.000 0.172 0.005
Hyper
fluorescence

Identification 0.920 0.000 0.828 0.000 0.941 0.000 0.906 0.000 0.939 0.000 0.843 0.000
of MAs

Capillary 0.976 0.000 0.930 0.000 0.976 0.000 0.908 0.000 0.953 0.000 0.886 0.000
Non-
Perfusion

Leakages 0.935 0.000 0.936 0.000 0.957 0.000 0.979 0.000 0.978 0.000 0.957 0.000
from RNV

Image 0.510 0.000 0.389 0.000 0.618 0.000 0.242 0.000 0.461 0.000 0.217 0.002
Quality

Abbreviations: DVS, Deependra Vikram Singh; GM, Gaurav Mathur; RB, Rishi Bhardwaj; FAZ, Foveal Avascular Zone; BRV, Branch
Retinal Vein; MAs, Microaneurysms; RNV, Retinal Neovascularization.
NC* Kappa analysis cannot be computed due to lack of similar variables in these cross tables. (some grades had zero values)

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Results could be identified in 51/60 eyes on FFA Images from Standard
Camera and 47/60 eyes on FFA Images from low-cost Camera
Total of 91 eyes of 46 patients were included for Image analysis. by PI. The agreement between two devices calculated by
Total of 1647 (18 per eye) FFA images from low-cost Fundus Kappa analysis was 0.924 (very good agreement) with P
camera and 1596 (17.5 per eye) FFA images from standard value of 0.000. Similar Analysis for agreement between two
camera were graded. Grading of FFA images captured by devices on identification of Microaneurysyms was done for
both devices was done for each eye by 3 Retinologists – DVS
(PI), GM (CI) & RB (CI). The Demographic data and Ocular Figure 1: FFA images from case ID 31 showing OD with Non-Proliferative
characteristics of these 46 patients is listed in (Table - 2). Diabetic Retinopathy. FAZ is nicely visualized in FFA images from both low-
Results of kappa analysis for intra-observer agreement cost (1A) and Standard Fundus (1B) Cameras. Please note timing displayed
for grading these 7 parameters on FFA images from both (white solid arrow) in second image (1B) is irrelevant because FFA was done
devices by 3 retinologists are discussed here. Results of
interobserver agreement are shown in (Table 3). Detailed sequentially on two cameras
statistical results are available as supplementary material
(Annexure -1). Figure 2: FFA images from case ID 22 showing OD with Central serous
1. FAZ (Percentage of FAZ Visible) – chorioretinopathy (CSCR) with stippled hyper fluorescence due to chronic
FAZ was evaluated and graded into 4 scales ranging from RPE alterations (Solid white arrows), and ink blot leakage (hollow white
A to D with Grade D showing best visualization (Table–1). arrows). Also, seen is bright hyper fluorescence suggestive of Pigment
Grading of FFA Images from Standard Camera revealed FAZ epithelial detachment (PED) (White arrow heads). Both Images are showing
visualization to be Grade D (75% to 100% FAZ visualized) in
85/91 (93.41%) eyes as compared to FFA images from low- all abnormal hyper fluorescence at macula.
cost Camera where FAZ visualization was Grade D (75% to
100% FAZ visualized) in 69/91 (75.82%) eyes when graded Figure 3: FFA images from case ID 29 showing OD with PDR with
by PI. The agreement between the two devices calculated by microaneurysms (MAs) visible as hyperfluorescent dots (white arrows)
Kappa analysis was 0.302 (fair agreement) (p = 0.000). The p
value here signifies the validity of the test (Cohen’s Kappa), scattered over macula and leakage from neovascularization at disc.
yet, bears no implication on the test value itself.
Similar Analysis for agreement between two devices was
done for 2 CIs (GM and RB). The agreement on kappa
analysis was 0.339 (fair agreement) (p = 0.00) for GM and
0.105 (poor agreement) (p = 0.020) for RB. Figure 1 shows
a case where FAZ in nicely visualized in FFA images from
both devices.
2. Branch Retinal Vessel Identification –
All 1st, 2nd and 3rd order Branch Retinal vessels were visible
in 89/91 (97.8%) eyes on Zeiss FFA Images and in 82/91
(92.11%) eyes on Optomed FFA Images. The agreement
between two devices calculated by Kappa analysis was 0.347
(Fair agreement) with P value of 0.000.
Similar Analysis for agreement between two devices for
branch vessel identification was done for 2 CIs (GM and RB).
The agreement on kappa analysis was 0.175 (poor agreement)
(with p = 0.018) for GM and 0.128 (poor agreement) (with p
= 0.003) for RB.
3. Identification of any abnormal hyper fluorescence at
macula –
Abnormal Hyper fluorescence at macula was detected in 80/91
eyes on Zeiss Images and 78/91 eyes on Optomed Images by
PI. The agreement between two devices calculated by kappa
analysis was 0.768 (good agreement) with P value of 0.000.
Similar Analysis for agreement between two devices on
identification of any abnormal hyper fluorescence was done
for 2 CIs (GM and RB). The agreement on kappa analysis
was 0.950 (very good agreement) (p = 0.00) for GM and 0.724
(good agreement) (p = 0.00) for RB. Figure 2 shows variety
of abnormal hyper fluorescences visualized in images from
both devices.
4. Identification of Micro aneurysms –
60 eyes with diabetic retinopathy or RVO were eligible for
detection of possible microaneurysms. Microaneurysyms

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2 CIs (GM and RB). The agreement on kappa analysis was for RB. Figure 4 shows a case with (Branch Retinal Vein
0.899 (good agreement) (p = 0.00) for GM and 0.961 (very Occlusion) BRVO and retinal edema seen as equally well
good agreement) (p = 0.00) for RB. Figure 3 shows multiple delineated in FFA images from both devices.
MAs nicely visible as hyperfluorescent dots of uniform size
in FFA images from both devices. Discussion
5. Identification of capillary non perfusion areas
32 eyes with severe NPDR and RVO were eligible for In this clinic-based comparative instrument validation
evaluation of Capillary non perfusion (CNP). CNP areas study, we evaluated the performance of a low cost portable
could be identified in 31/32 eyes on Images from Standard FFA camera (Smartscope®, Optomed Inc, Oulu, Finland) by
Camera and 29/32 eyes on Images from low-cost Camera by comparing its FFA images with standard camera (Carl Zeiss
PI. The agreement between two devices calculated by Kappa Inc., San Leandro, CA). We performed Kappa analysis on
analysis was 0.976 (very good agreement) with P value of grading on Images from 2 devices done by 3 Retinologists
0.000. Similar Analysis for agreement between two devices and found a very high agreement (value of k > 0.6) between
on identification of capillary non perfusion areas was done two devices for 4 out of 7 parameters. These parameters
for 2 CIs (GM and RB). The agreement on kappa analysis were Identification of any abnormal hyper fluorescence at
was 0.977 (very good agreement) (p = 0.00) for GM and 0.954 macula, Identification of Micro aneurysms, Identification of
(very good agreement) (p = 0.00) for RB. capillary non perfusion areas and identification of leakage
6. Leakages from RNV from retinal neovascularization. Inter-observer agreement
32 eyes with severe NPDR and RVO were eligible for for 3 Retinologists (DVS, RB & GM) in grading FFA images
evaluation of Leakage from Retinal Neovascularization from two devices was found to be good or better (Kappa
(RNV). Leakage from RNV could be identified in 24/32 >0.6) for 3 features out of these 7 parameters.
eyes on Standard Fundus Camera (Zeiss) Images and 21/32 However, for parameters like FAZ visualization, identifying
eyes on Low-cost Fundus Camera (Optomed) Images by PI. branch retinal vein and Image quality, the agreement between
The agreement between two devices calculated by Kappa 2 devices was fair to poor. Results for these parameters were
analysis was 0.935 (very good agreement) with P value of same for interobserver agreement between graders. We
0.000. Similar Analysis for agreement between two devices feel that these categories could have been more objectively
on identification of leakages from RNV was done for 2 CIs defined to make grading for these 3 features less subjective
(GM and RB). The agreement on kappa analysis was 0.936 and this could explain the lack of agreement. The fact that
(very good agreement) (p = 0.00) for GM and 0.957 (very the “Interobserver agreement between 3 graders on these 3
good agreement) (p = 0.00) for RB. features was poor even with standard (Zeiss) camera that is
7. Image Quality known to produce high quality FFA images:” supports our
Image quality was graded as excellent (details of All vessels hypothesis that these were too subjective parameters.
seen and FAZ seen clearly) in 84/91 eyes on Standard Identification of Micro aneurysms, Identification of capillary
Fundus Camera (Zeiss) Images and 68/91 eyes on Low-cost non perfusion areas and identification of leakage from retinal
Fundus Camera (Optomed) Images by PI. Image quality neovascularization are 3 important parameters for which a
was graded as poor (only Disc and Macula seen) in 1/91 eyes retinologists would order a FFA test and these FFA findings
on Zeiss Images and 5/91 eyes on Optomed Images by PI. are utilized for managing eyes with diabetic retinopathy,
The agreement between two devices calculated by Kappa RVO, Retinal vasculitis and same applies to detection of
analysis was 0.268 (fair agreement) (p = 0.00). Overall, abnormal hyper fluorescence in eyes with CSCR.
89/91 (97.8%) eyes in Zeiss group and 83/91 (91.2%) eyes in This study has found very good inter-device (Zeiss
Optomed group had excellent to good image quality FFA Vs Optomed) agreement and very good interobserver
images. Similar Analysis for agreement between two devices agreement (for Optomed) while grading FFA images for
on Image Quality was done for 2 CIs (GM and RB). The these parameters implying that this low-cost (≈US $8600.00)
agreement on kappa analysis was 0.137 (poor agreement) Fundus camera can substitute for a (higher cost) (≈US
(p = 0.014) for GM and - 0.013 (poor agreement) (p = 0.769) $34500.00) Standard Fundus Camera.
In India, more than 62 million individuals are currently
Figure 4: FFA images from case ID 39 showing OD with fresh BRVO with diagnosed with Diabetes11 and the ophthalmologist to
macular edema. Extent of involvement is well delineated in both images. population ratio is 1:107 000. Although 70% of the population
lives in rural areas, 70% of ophthalmologists practice in
urban areas.14,15 This discrepancy creates a significant need
for outreach programs. This also means that affordability
and accessibility to retina care is lacking significantly in
rural areas. Most tier-2 and tier-3 cities get retina care
by visiting retinologists who travel from tier-1 cities
and deliver retina services for different retinal disorders
including management of Diabetic retinopathy. Importance
of using a low cost portable FFA camera with acceptable
performance on Image quality and good performance on
relevant (decision influencing) parameters in this setting
cannot be over emphasized. Current study has provided

E-ISSN: 2454-2784  P-ISSN: 0972-0200 69 Delhi Journal of Ophthalmology

DJO Vol. 31, No. 2, October-December 2020

useful insights into decision influencing parameters-based (ICMRINDIAB) study. Diabetologia. 2011; 54:3022–7.
assessment of a low-cost FFA Camera. Recently published 7. Bressler NM, Varma R, Doan QV, et al. Underuse of the health
guidelines from International Council of Ophthalmology
has acknowledged the prohibitive cost of OCT in low and care system by persons with diabetes mellitus and diabetic
intermediate resource settings.16 In this scenario a low cost macular edema in the United States. JAMA Ophthalmol. 2014;
FFA can assist retinologists in detecting and documenting 132:168–73.
findings, like macular edema and serous detachment and 8. Fletcher AE, Donoghue M, Devavaram J, et al. Low uptake of
leaks in CSCR, that could impact and also guide the clinical eye services in rural India: a challenge for programs of blindness
treatment decisions for these retinal diseases. prevention. Arch Ophthalmol. 1999; 117:1393–9.
Merits of this study include; it was an observational validation 9. Sengupta S, Sindal MD, Besirli CG, Upadhyaya S, et al.
study with Simultaneous FFA done on both devices, both Screening for vision-threatening diabetic retinopathy in South
cameras were randomly used to click early phases in subjects India: comparing portable non-mydriatic and standard fundus
and FFA images were graded by 3 experienced retinologists cameras and clinical exam. Eye (Lond). 2018 Feb;32(2):375-383.
and relevant Image parameters for grading were used to 10. Bursztyn L, Woodward MA, Cornblath WT, et al. Accuracy and
assess angiography performance. We are also unaware of Reliability of a Handheld, Nonmydriatic Fundus Camera for the
any other study evaluating angiography performance of a Remote Detection of Optic Disc Edema. Telemed J E Health. 2018
portable FFA Camera. However, there were some limitations May;24(5):344-350.
of this study including a small sample size, Eyes with 11. Joshi SR, Parikh RM. India - diabetes capital of the world:
significant cataract or PCO were excluded, Graders could now heading towards hypertension. J Assoc Physicians India.
not be blinded because of the different characteristics of 2007;55:323–4.
Images from both devices and also, we didn’t analyze the 12. Garcia CR, Rivero ME, Bartsch DU, et al. Oral fluorescein
performance of this low-cost camera on peripheral FFA angiography with the confocal scanning laser ophthalmoscope.
imaging but same was not possible with Standard FFA Ophthalmology. 1999 Jun;106(6):1114-8.
camera either. Need to evaluate performance of this low-cost 13. Altman DG. Practical Statistics for Medical Research. (1991)
portable camera for other retinal diseases like AMD and in a London England: Chapman and Hall. Page No. 404.
larger population cannot be over emphasized. 14. Kumar R. Ophthalmic manpower in India—need for a serious
review. Int Ophthalmol. 1993; 17(5): 269–275.
Conclusion 15. Samandar R, Kleefield S, Hammel J, Mehta M, Crone R. Privately
funded quality health care in India: a sustainable and equitable
Over all, we found that Fluorescein Angiography model. Int J Qual Heal Care 2001; 13(4): 283–288.
performance of Low cost (Optomed) Fundus camera was 16. Wong TY, Sun J, Kawasaki R, Ruamviboonsuk P, Guidelines on
comparable to Standard (Zeiss) Fundus camera especially Diabetic Eye Care: The International Council of Ophthalmology
for objective features like identification of abnormal hyper Recommendations for Screening, Follow-up, Referral, and
fluorescence, MAs, CNP areas and leakages from RNV in Treatment Based on Resource Settings. Ophthalmology. 2018
eyes with diabetic retinopathy, RVO, CSCR and Retinal Oct;125(10):1608-1622.
vasculitis. Because these FFA findings influence clinical
decision for managing these retinal disorders, we can safely Cite This Article as: Deependra Vikram Singh, Gaurav Mathur,
conclude that this camera is a useful low-cost alternative Rishi Bhardwaj, Ajay Sharma Low-cost Fundus Fluorescein
to gold standard high cost (Zeiss) camera in low resource Angiography, Portable Fluorescein Angiography, Diabetic
settings. Retinopathy, Hyperfluorescence. Delhi J Ophthalmology. 2020; 31
(2): 65-70
References
Acknowledgments: Rajat Goel, Anurag Gupta, Sachin Wangoo .
1. Flaxman SR, Bourne RRA, Resnikoff S et al. Global causes
of blindness and distance vision impairment 1990-2020: a Conflict of interest: None
systematic review and meta-analysis. Lancet Glob Health. 2017
Dec;5(12):e1221-e1234 Source of Funding: This Study was supported by Grant from IFC,
World Bank
2. Whiting DR, Guariguata L, Weil C, Shaw J. IDF diabetes atlas:
global estimates of the prevalence of diabetes for 2011 and 2030. Date of Submission: 30th March 2020
Diabetes Res Clin Pract. 2011; 94:311–21. [PubMed: 22079683]. Date of Acceptance: 7th June 2020

3. Yau JWY, Rogers SL, Kawasaki R, et al. Global prevalence and Address for correspondence
major risk factors of diabetic retinopathy. Diabetes Care. 2012;
35:556–64. [PubMed: 22301125]. Deependra Vikram Singh MD

4. Jonas JB, Bourne RR, White RA, Flaxman SR. Visual Impairment Eye-Q Superspecialty Eye Hospitals
and Blindness Due to Macular Diseases Globally: A Systematic H.NO – 522, Sec-27. Sushant Lok,
Review and Meta-Analysis. Am J Ophthalmol 2014;158:808–815. Gurugram, India, 122002
Email - [email protected]
5. Song P, Xu Y, Zha M, Zhang Y, Rudan I. Global epidemiology
of retinal vein occlusion: a systematic review and meta-analysis Quick Response Code
of prevalence, incidence, and risk factors. J Glob Health. 2019
Jun;9(1):010427.

6. Anjana RM, Pradeepa R, Deepa M, et al. Prevalence of diabetes
and prediabetes (impaired fasting glucose and/or impaired
glucose tolerance) in urban and rural India: phase I results
of the Indian Council of Medical Research-India Diabetes

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DJO Vol. 31, No. 2, October-December 2020

Case Report

Visual Loss following Daily Dose Regimen of Anti Tubercular
Treatment

Silni Chandra, Ranjini K. Christie Sarah Mathew

Department of Ophthalmology, Government Medical College Kozhikode, Kerala, india.

Abstract This article is to report on the increasing trend of visual loss following daily regimen of Anti Tubercular treatment.
Review of 15 patients who presented with varying degrees of visual loss after starting Anti Tubercular treatment
was done. The patients had variable time of presentation ranging from few weeks to 3 months. Pupillary reaction
was bilaterally brisk but ill sustained in 80% cases. Fundus examination showed optic disc changes only in 20% cases.
Ethambutol was stopped in all cases. 46.6% patients were given systemic steroids. Patients who presented early had
better visual prognosis. No treatment was found to be effective in reversing the optic neuropathy except stopping of
Ethambutol. Only early diagnosis could prevent total visual loss. Till the time the causes and risk factors get better
elucidated it would be prudent to have a regular Ophthalmological evaluation of all patients who are started on
daily regimen of anti-tubercular treatment.

Delhi J Ophthalmol 2020;31;71-74; Doi http://dx.doi.org/10.7869/djo.595

Keywords: Tuberculosis, Visual Loss, Daily Dose Regimen

Introduction Methods

Tuberculosis, an infectious disease caused by Mycobacterium This study is a retrospective chart review of 15 patients who
Tuberculosis has seen a resurgence since last few years. developed visual loss after treatment with the daily regimen
The presence of multi drug resistant Tuberculosis has of Anti Tubercular Treatment (ATT)for a period ranging
also shown an upswing. In India, the diagnosis and from 1 month to 1 year. They presented to the outpatient
treatment of tuberculosis is based on the Revised National department of Ophthalmology of Government Medical
Tuberculosis control program which was started in 1997, by College, Kozhikode, Kerala, India between January2018 to
the Government of India. Earlier all new patients received June 2019. Details regarding the age, gender, duration of
an initial intensive phase of four medications for eight ATT taken, comorbidities, renal status, smoking or alcohol
weeks. It included Isoniazid, Rifampicin, Pyrazinamide and dependence, time when the visual symptoms were noticed
Ethambutol. It was followed by continuation phase of two after starting ATT were noted. Clinical features included
medications for sixteen weeks. This was under the WHO visual acuity, anterior segment findings, pupillary reaction,
approved DOTS Regime (Directly observed Treatment, color vision, visual field, fundus findings at presentation and
short course). The treatment was provided for three days a in last follow up, visually evoked potential(VEP), treatment
week and all drugs were given separately. This regimen was given, fundus picture and visual acuity at last follow up
later found to promote relapse and generated drug resistant and the time period that the patient has been on follow up
strains and the relapsed cases were also found to be difficult were noted. Only those patients whose visual symptoms
to treat. developed after the initiation of daily regimen of ATT and
In 2014 RNTCP recognized the need for daily dosing and in whom the symptoms could be attributed to the Anti
the new regimen was implemented from February 2017. tubercular treatment and had been on follow up for at least
Under the new daily drug regimen Patients are given fixed 6 months were included in the study
dose combinations (FDC) of 4 drugs according to patients’
weight, in a single pill on a daily basis. This is followed Results
for 6-8 months. The patients are supervised by the DOTS
strategy. They are given a combination of Isoniazid 5 Demographic Characteristics- The age of the patients
mg/kg/day, Rifampicin 10 mg/kg/day, Ethambutol 14.5- ranged from 34 to 75 years. 8 (53%) patients were male and
21.4 mg/kg/day and Pyrazinamide 18.2-26.3 mg/kg/day. 7(46.6%) patients were female. All patients presented with
Maximum recommended dose of Ethambutol is 1500mg/ diminution of vision bilaterally which started after 1 month
day. Ethambutol toxicity has been identified as dose related. to 9 months of starting daily regimen of ATT treatment.
So patients receiving higher doses of ethambutol according They presented to the hospital within 15 days to 3 months
to the new regimen of RNTCP should be at greater risk of of onset of symptoms. 5 patients (33%) had received ATT for
developing Ethambutol induced adverse effects the most pulmonary tuberculosis, 7 (46.6%) patients for Potts spine,
common of which is Optic neuropathy 1 (6%) patient for laryngeal tuberculosis, 1 (6%) patient for
intestinal tuberculosis and 1 patient (6%) for lupus vulgaris.
7(46.6%) patients had associated diabetes mellitus and
hypertension, 1 (6%) patient had peripheral vascular disease,
1 (6%) patient had a seizure disorder, 1(6%) patient had a

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DJO Vol. 31, No. 2, October-December 2020

Table 1: Master Chart showing the details of the 15 patients who developed visual loss following daily dose regiment of ATT

Figure 1: Central & Centrocaecal Scotoma in a patient with Asymmetric vision loss and the other with a vision ranging from 6/60 to
visual loss due to Ethambutol induced optic neuropathy 6/18. 1 patient (6%) presented with visual acuity of 6/9 and
6/18 in RE and LE respectively with no further improvement.
history of cerebrovascular accident and 1 (6%) patient had 6 (85.7%) patients out of 7 with profound loss of vision had
a chronic kidney disease. All diabetic patients had a normal presented late for ophthalmological evaluation at around
renal profile. Only 3 (20%) patients had a history of smoking 3 months. Rest of the patients presented between 2 weeks
and alcohol consumption for many years. to less than 3 months. 1 patient with bilateral severe visual
impairment did not reveal her history of ATT intake till 3
Clinical features months even though she remained on continuous follow up
for her diabetic retinopathy.
Visual acuity- 7(46.6%) patients had a profound loss of Anterior segment was unremarkable in all patients except
vision in both eyes i.e. VA <3/60.3 (20%) patients had bilateral 2(13.3%) who had nuclear sclerosis grade 2. Pupillary
severe visual impairment (3/60 – 6/60). 4 patients (26.6%) reaction was bilaterally brisk but ill sustained in 12 (80%)
had asymmetric presentation with one eye having profound patients. 3 patients (20%) had Grade 1 relative afferent
pupillary defect (RAPD) in the more severely affected eye
while the other eye showed a sluggish pupillary reaction.
Color vision tested using Ishihara’s color plates, was
defective bilaterally in 11 (73.3%) patients while in 3(20%)
patients it could not be tested due to profound loss of vision.
In 1 (6%) patient there was a loss of color vision in only the
severely affected eye.
Field examination showed a hemianopic field defect in
1 (6%) patient with profound loss of vision. Rest of the
patients with profound loss of vision the field examination
was not possible. Field examination showed central scotoma
and centrocaecal scotoma (Figure 1) with peripheral field
constriction in 9 (30%) eyes of 7 patients with bilateral severe
visual impairment and patients with asymmetric loss of
vision. 1 (6%) with minimal loss of vision did not have any
visual field defect
12 eyes of 7 patients (40%) had minimal optic disc pallor at
the time of presentation, 6 (20%) eyes of 4 patients had optic
disc edema and 12 (40%) eyes of 7 patients had normal optic
disc at presentation. 1 (6%) patient with normal optic disc
had a macular scar bilaterally at the time of presentation
and had a history of poor vision since young age. 1 (6%) had
moderate non proliferative diabetic retinopathy with non-
center involving macular edema in both eyes
VEP was done in 10 (66.6%) patients and it showed an absence
of waves bilaterally in 8 patients (80%) and low amplitude
with prolonged latency in BE of 2 patients (22.2%).

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DJO Vol. 31, No. 2, October-December 2020

Magnetic resonance imaging of the brain was carried out These patients did not show any improvement but further

in 3 patients (20%) which showed small vessel disease in loss of vision could be prevented.

2 patients and an old infarct in the midbrain in 1 patient In the patients who recovered their visual acuity 50%

"Demographic and clinical features are further described in patients had no comorbidities while 50% were diabetic with

(Table 1)." Treatment normal renal functions(3). 6% patients had chronic kidney

disease and did not recover any vision even after cessation

All patients were advised to stop Ethambutol with immediate of Ethambutol. Renal disease has been a known risk factor

effect after consultation with their RNTCP physician. 2(13.3 for development of optic neuropathy following ATT. There

%) patients with profound loss of vision who did not were 46.6% diabetic patients and hypertensive patients all of

show any improvement even after stopping Ethambutol whom had normal renal profile at the time of presentation

for 1-2 weeks were advised to stop Isoniazid. 7 patients and during follow up too. Patients with altered renal status

(46.6%) were started on systemic steroid: 2 patients (13.3%) require more frequent follow up with their ophthalmologists

were given pulse therapy of methyl prednisolone 1 gram as the risk of Ethambutol induced optic neuropathy is found

intravenously for 3 days and then oral steroids on tapering to be more in patients with reduced glomerular filtration

schedule. 2 patients (13.3%) were given injectable steroids rate since ethambutol is mainly excreted through kidney.2

2cc intravenously twice a day for 5 days and then gradually None of these patients who recovered their vision had any

tapered and 3 patients (20%) were given oral steroids 40- 60 history of smoking or alcohol consumption. Only 20% of

mg twice daily for 5 days then tapered over a week. All were patients in this group had history of smoking and alcohol

given methyl cobalamine and multi vitamin tablets. intake. All of them maintained their visual acuity following

At the last follow up at 6 months, 6(20%) eyes of 4 patients stoppage of Ethambutol.

with optic disc edema went into secondary optic atrophy, Among the patients who recovered vision 12.5% eyes had

10(33.3%) eyes of 6 patients with normal optic disc continued unilateral optic disc edema 50% eyes had a normal fundus

to have a similar fundus picture at last follow up at 6 at presentation while 37.5% eyes had a mild temporal pallor.

months 2 eyes (6%)of a single patient with normal disc at This was in contrast to the findings in previous studies in

presentation developed temporal disc pallor. 12 (40%) eyes which presence of optic disc pallor was a poor prognostic

of 7 patients had persistent or worsened temporal pallor at indicator.

the time of last follow up. Only 25% patients among those who recovered vision

Only 8 (26.6%) eyes of 4 patients showed any improvement were given systemic steroid intravenously which was

of vision. 2 eyes of single patient with profound loss of vision gradually tapered while the other patients were given oral

bilaterally showed an objective improvement in vision multivitamin and methycobalamine. Systemic steroids

from no perception of light (No PL) to 6/12 in BE. 4 eyes of either orally or intravenously or as pulse therapy were

2 patients with bilateral severe visual impairment showed given to 46.6% patients but only 14.2% patients out of these

improvement from 3/60 in RE and 5/60 in LE to 6/60 and recovered some vision. Though Ethambutol induced optic

6/36 in RE and LE respectively in 6 months. One patient with neuropathy is supposed to be reversible but it was not found

asymmetric visual loss showed improvement in vision from to be reversible in the majority of the patients in this group.

6/60 to 6/12 in right eye and while in left eye there was only 20% showed progression of visual loss even after stopping

a marginal improvement from CFCF to 2/60. ethambutol.

6 (20%) eyes of 3 patients showed deterioration of vision Creating awareness among patients and Ophthalmologists

even after stopping ethambutol. 14 (46.6%) eyes of 7 patients is the need of the hour since patients may not associate

showed stabilization of vision after stopping Ethambutol. visual loss to the anti-tubercular treatment and thus may

fail to inform the ophthalmologist regarding their ATT.5 This

Discussion may result in unnecessary investigations and lead to loss of

Ethambutol induced optic neuropathy is a well-recognized valuable time.
adverse effect which is dose and duration related.1 Prompt
recognition of symptoms of diminution of vision could This study has a few limitations. The number of patients has
help in drastically reversing the optic neuropathy in 6.6%
patients and marginally reversing it in 20% patients but rest been very few to fully understand the risk factors, causes
of the patients did not show any improvement .The studies
in the past have shown variability in the percentages of and treatment of ethambutol induced optic neuropathy. The
patients regaining their vision after stopping Ethambutol.
This variability could be due to the difference in the follow role of Isoniazid has not been investigated. The relationship
up period of these patients apart from many known and
unknown factors.2,3 between the cumulative dose of Ethambutol, the weight of
The patients who recovered their vision came within 2
weeks to 1 month of their onset of visual symptoms.4 All the individual and the severity of the visual loss has not been
patients who reported late after their visual symptoms
started did not benefit by stopping of Ethambutol. 13.3 % of studied. The role of contrast sensitivity in early diagnosis of
patients were also advised to stop Isonazid when stopping
of Ethambutol was not found to be effective after 2-3 weeks. optic neuropathy has not been looked into.[4] The follow

up period is also a limiting factor in the study. The present

daily dose regimen does not include tablet pyridoxine tablet

which was earlier included in the regimen. Whether this had

any role to play in the development of visual loss needs to

be investigated Conclusions

Adverse drug reactions to ATT has seen an increase following

the daily regimen of Anti Tubercular treatment. This calls

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DJO Vol. 31, No. 2, October-December 2020

for a more rigid regimen of ophthalmological evaluation 4. Jin KW, Lee JY, Rhiu S, Choi DG. Longitudinal evaluation
and follow up for all patients who are started on this new of visual function and structure for detection of subclinical
regimen. This would help in early detection of drug induced Ethambutol-induced optic neuropathy. PLoS ONE [Internet].
optic neuropathy and other adverse drug reactions which 2019 Apr 17 [cited 2020 Apr 26];14(4). Available from: https://
may help in saving the vision of the patient before irreversible www.ncbi.nlm.nih.gov/pmc/articles/PMC6469811/
damage has happened. This article is a small step in this
direction to create awareness among all ophthalmologists 5. Mehta S. Patterns of Ethambutol Ocular Toxicity in Extended Use
regarding this drug induced optic neuropathy following Therapy. Cureus [Internet]. [cited 2020 Apr 26];11(4). Available
daily regimen of anti-tubercular treatment. from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6559692/

References Cite This Article as: Silni Chandra, Ranjini K. Christie Sarah
Mathew. Visual loss following daily dose regimen of Anti
1. Lee J-Y, Choi JH, Park K-A, Oh SY. Ganglion Cell Layer and Inner Tubercular Treatment. DJO 2020;31 (2): 71-74
Plexiform Layer as Predictors of Vision Recovery in Ethambutol-
Induced Optic Neuropathy: A Longitudinal OCT Analysis. Acknowledgments: Nil
Invest Ophthalmol Vis Sci [Internet]. 2018 Apr 1 [cited 2020 Apr
26];59(5):2104–9. Available from: https://iovs.arvojournals.org/ Conflict of interest: None declared
article.aspx?articleid=2679335
Source of Funding: None
2. Lee EJ, Kim S-J, Choung HK, Kim JH, Yu YS. Incidence and
Clinical Features of Ethambutol-Induced Optic Neuropathy in Date of Submission: 08 Jan 2020
Korea. J Neuroophthalmol [Internet]. 2008 Dec [cited 2020 Jan Date of Acceptance: 03 May2020
8];28(4):269. Available from: https://journals.lww.com/jneuro-
ophthalmology/fulltext/2008/12000/Incidence_and_Clinical_ Address for correspondence
Features_of.2.aspx
Silni Chandra Assistant Professor,
3. Chen S-C, Lin M-C, Sheu S-J. Incidence and prognostic factor
of ethambutol-related optic neuropathy: 10-year experience in Department of Ophthalmology,
southern Taiwan. Kaohsiung J Med Sci [Internet]. 2015 [cited Government Medical College,
2020 Apr 26];31(7):358–62. Available from: https://onlinelibrary. Kozhikode, Kerala, India
wiley.com/doi/abs/10.1016/j.kjms.2015.05.004 Email [email protected]

Quick Response Code

E-ISSN: 2454-2784  P-ISSN: 0972-0200 74 www.djo.org.in

DJO Vol. 31, No. 2, October-December 2020

Case Report

Late Opacification of PCIOL

Abstract Mohmad Uzair, Amit Mehtani, Deepak Varma, Jatinder S. Bhalla,

Department of Ophthalmology, Deen Dayal Upadhyay Hospital, Hari Nagar, New Delhi, India.

A 63 year male presented with diminished vision in right eye from the past 6 months. The patient had undergone
cataract surgery in both eyes. The right eye was operated in 5 years back and left eye was operated in 6 years
back. The patient was asymptomatic for 4.5 years postoperative when he started to notice glare in his vision in the
right eye. The glare gradually progressed to diminished vision in the right eye. On slit lamp biomicroscopy, a well
centered foldable PCIOL was seen with multiple crystalline opacities. On examination at higher magnification, the
opacities were found to be within and around the optic substance. Patient underwent IOL exchange with acrylic
hydrophobic PCIOL. The Explanted IOL was found with very large calcified deposits on the surface of the lens, as well
as smaller multiple calcified deposits within the subsurface of the lens, in both optic and loop components.

Delhi J Ophthalmol 2020;31;75-77; Doi http://dx.doi.org/10.7869/djo.596
Keywords: Iol Opacification, Tertiary Cataract

Introduction found to be within and around the optic substance (Figures
1B). The left eye was pseudophakic with
The opacification of hydrophilic acrylic intraocular a vision of 6/6 (unaided). No abnormalities were found in the
left eye. Patient’s right eye underwent IOL exchange with
lenses (IOLs) is a rare complication, usually occurring
in the late postoperative period1. The exact causes and Figure 1: Anterior segment photograph on dilated examination, showing
opacification of whole of the PCIOL (including optic and both haptics).
pathomechanisms leading to hydrophilic IOL opacification

are unknown. There have been sporadic reports about high

incidences of IOL opacification affecting whole batches of

IOLs of individual manufacturers irrespective of secondary

surgical interventions or comorbidities,2–4 so that material

impurities and faulty manufacturing or storage as well

as interactions with the packaging material have been

suggested as causative factors in these cases. Individual

factors, such as ocular inflammation or ocular and systemic

comorbidities that affect ocular metabolism, may contribute

to the process.3 Case report

A 63 year male presented with diminished vision in right

eye for the past 6 months. The diminution in vision was

of insidious onset, gradually progressive, and painless.

The patient did not have any history of pain, redness,

photophobia, flashes, floaters, trauma or any systemic illness,

However, he gave a history of some glare in initial days of

the complaint. The patient had undergone cataract surgery

in both eyes. The right eye was operated in 5 years back and

left eye was operated in 6 years back and on documentation

the implanted IOLs were hydrophilic acrylic. The pre , intra-,

and post operative period was uneventful. The surgeries had

good visual outcome. The patient did not undergo any other

ocular surgical procedure. The patient was asymptomatic for

4.5 years postoperative when he noticed glare in the right eye.

The glare gradually progressed to diminished vision in the

right eye. On presentation, the patient could barely perceive

hand motions close to face with his right eye. On torch light

examination, there was presence of white pupillary reflex in

right eye appearing to be white mature cataract. The vision

in right eye was <1/60 with accurate projection of rays.

Pupillary reactions were within normal limits. On slit lamp

biomicroscopy, a well centered foldable IOL placed in bag

was seen with multiple crystalline opacities (Figure 1A).

On examination at higher magnification, the opacities were

E-ISSN: 2454-2784  P-ISSN: 0972-0200 75 Delhi Journal of Ophthalmology

DJO Vol. 31, No. 2, October-December 2020

acrylic hydrophobic PCIOL. Viscoelastic injected 360 degree protein and calcium could be promoted by long-chain fatty
acids. The adsorption of such macromolecules could provoke
under the edge of capsular rim till complete dissection from the formation of a calcification nucleus.11 The exact causes
and patho mechanisms are still unknown.12,13 However, our
IOL, viscodissection was performed to separate iol from case did not have any form of known ocular pathology in
his eye. Such cases compromise the visual outcome even
capsular bag, IOL prolapsed in anterior chamber with the in uneventful cataract surgery cases, and we do not have
enough data to prevent such occurrences.14,15 The best line
help of second instrument, iol was bissected with vannas of management in such cases will be explant of the IOL in
question and proceed with a secondary IOL implant in the
scissor and was removed from the main port. The patient had same sitting or a later date.16

uneventful pre, intra and postoperative period with good References

visual recovery. The Explanted IOL was found with very 1. Werner L. Causes of intraocular lens opacification or
discoloration. J Cataract Refract Surg. 2007;33(4):713–26.
large calcified deposits on the surface of the lens, as well as
2. Izak AM, Werner L, Pandey SK, Apple DJ. Calcification of
smaller multiple calcified deposits within the subsurface of modern foldable hydrogel intraocular lens designs. Eye (Lond).
2003;17(3):393–406.
the lens, in both optic and loop components. The confluent
3. Tandogan T, Khoramnia R, Choi CY, et al. Optical and
nature of the deposits compromised the vision of the patient material analysis of opacified hydrophilic intraocular lenses
after explantation: a laboratory study. BMC ophthalmology.
largely. Discussion 2015;15:170.

Various pathologic processes may lead to clinically 4. Bompastor-Ramos P, Povoa J, Lobo C, et al. Late postoperative
opacification of a hydrophilic-hydrophobic acrylic intraocular
significant opacification or discoloration of the optic lens. J Cataract Refract Surg. 2016;42(9):1324–31.

component of intraocular lenses manufactured from 5. Jorge Pde A, Jorge D, Ventura CV, Ventura BV, Lira W, Ventura
MC, Werner L, et al. Late opacification in hydrophilic acrylic
different biomaterials and in different designs. Factors such intraocular lenses: Analysis of 87 eyes in a random sample of 102
patients. J Cataract Refract Surg. Mar 2013;39(3):403-407.
as the patient's associated conditions, the manufacturing
6. Nakanome S, Watanabe H, Tanaka K, Tochikubo T. Calcification
process, the method of IOL storage, the surgical technique of Hydroview H60M intraocular lenses: Aqueous humor analysis
and comparisons with other intraocular lens materials. J Cataract
and adjuvants, or a combination of these may be involved. Refract Surg. 2008;34(1):80-6.

Hydrophobic materials are specially opacified by excess 7. Pandey SK, Werner L, Apple DJ, Kaskaloglu M. Hydrophilic
acrylic intraocular lens optic and haptics opacification in a
influx of water, while hydrophilic IOLs are mostly affected diabetic patient: Bilateral case report and clinicopathologic
correlation. Ophthalmology. 2002;109(11):2042-51.
by the formation of deposits/precipitates on the IOL
8. Lee SJ, Choi JH, Sun HJ, Choi KS, Jung GY. Surface calcification
surface or within the IOL substance..5 Furthermore, direct of hydrophilic acrylic intraocular lens related to inflammatory
membrane formation after combined vitrectomy and cataract
discoloration by capsular dyes or medications, coating by surgery. Journal of Cataract and Refractive Surgery. J Cataract
Refract Surg. 2010;36(4):676-81.
substances such as ophthalmic ointment and silicone oil,
9. Werner L. Calcifification of hydrophilic acrylic intraocular lenses.
and a slow, progressive degradation of the IOL biomaterial Am J Ophthalmol 2008;146:341–3.

may be involved in the different designs of IOL opacification 10. Amon M. Biocompatibility of intraocular lenses. J Cataract
Refract Surg 2001;27:178 –9.
process.
11. Linnola RJ, Werner L, Pandey SK, et al. Adhesion of fifi-bronectin,
According to the literature, hydrophilic acrylic IOLs are likely vitronectin, laminin, and collagen type IV to intraocular lens
to develop calcification when the concentrations of calcium, materials in pseudophakic human autopsy eyes. Part 2: explanted
phosphate and albumin in the aqueous humor fluctuate intraocular lenses. J Cataract Refract Surg 2000;26:1807–18.
due to blood-aqueous-barrier breakdown or other factors.
Because the aqueous humor turns over every 90 minutes, it 12. Izak AM, Werner L, Pandey SK, Apple DJ. Calcification of
is significantly affected by concentrations of elements in the modern foldable hydrogel intraocular lens designs. Eye (Lond)
blood.6 That is why long-term observation is necessary after 2003;17:393-406.
implantation of hydrophilic acrylic IOLs, especially in cases
in which blood-aqueous barrier breakdown is suspected, as 13. Tandogan T, Khoramnia R, Choi CY, Scheuerle A, Wenzel
may occur in diabetes, uveitis and vitrectomy.7,8 M, Hugger P, et al. Optical and material analysis of opacified
In our case, we believe calcification of the hydrophilic hydrophilic intraocular lenses after explantation: A laboratory
acrylic lens lead to the IOL opacification . In our patient, study. BMC Ophthalmol 2015;15:170.
IOL opacification developed at 4.5 years after the
cataract surgery according to the clinical history and eye 14. Gartaganis SP, Kanellopoulou DG, Mela EK, Panteli VS,
examination, and the interval between cataract surgery and Koutsoukos PG. Opacification of hydrophilic acrylic intraocular
IOL explantation was 5 years. It is possible that the process lens attributable to calcification: Investigation on mechanism.
of IOL opacification in this case started before the patient’s Am J Ophthalmol 2008;146:395-403.
vision decreased. However, the process of calcification in
this case may take longer than that with other hydrophilic 15. Trivedi RH, Werner L, Apple DJ, Pandey SK, Izak AM. Post
IOLs. We hypothesize that the residual lens epithelial cells cataract intraocular lens (IOL) surgery opacification. Eye (Lond)
on the posterior capsule might slowly secrete crystalline. 2002;16:217 41.
It then took a long time for the deposition of calcium and
phosphorus on the protein film, which covers the posterior
surface of IOL.9 Several studies have demonstrated that
the eventual reaction to an IOL implanted into the eye
significantly depends on protein adsorption, especially in
the presence of microdefects on the polymer surfaces.10 After
absorption, the formation of tightly bound complexes of

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DJO Vol. 31, No. 2, October-December 2020

16. Mamalis N, Brubaker J, Davis D, Espandar L, Werner L.
Complications of foldable intraocular lenses requiring
explantation or secondary intervention-2007 survey update. J
Cataract Refract Surg 2008;34:1584-91.

Cite This Article as: Mohmad Uzair, Amit Mehtani, Deepak
Varma Jatinder S. Bhalla, Case report Late Opacification of PCIOL
Delhi J Ophthalmology. 2020;31 (2) :75-77
Acknowledgments: Nil
Conflict of interest: None declared
Source of Funding: None
Date of Submission: 29th April 2020
Date of Acceptance: 7th May 2020

Address for correspondence
Mohmad Uzair (M.S)

Senior Resident, Department of
Ophthalmology, Deen Dayal Upadhyay
Hospital, Hari Nagar, New Delhi- 110064.
Email id: [email protected]

Quick Response Code

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DJO Vol. 31, No. 2, October-December 2020

Case Report

Metastasis of Squamous Cell Carcinoma of Conjunctiva in
Anterior Chamber: A rare Case Report

Jayati Pandey, Perwez Khan, Alok Ranjan

Department of Ophthalmology, G.S.V.M Medical College, Kanpur.

Abstract A 65-year-old male presented with the chief complaint of diminution of vision , redness and mass in right eye
for 1 month who was then evaluated and investigated to know the cause. On examination and investigation
diagnosis of squamous cell carcinoma of ocular surface was made which had metastasized to anterior
chamber. Early diagnosis of SCC and commence of treatment is necessary to prevent its metastasis. Moreover,
patient’s compliance also plays a major factor to halt the progression.

Delhi J Ophthalmol 2020;31;78-79; Doi http://dx.doi.org/10.7869/djo.597

Keywords: Squamous cell carcinoma, Ocular surface, Metastasis

Introduction Case Report

Squamous cell carcinoma (SCC) of ocular surface occurs A 65-year-old male presented with complain of diminution
usually in interpalpebral area mostly at the limbus.1 It of vision in right eye since 1 month which was gradual in
represents a rare spectrum of disease ranging from mild onset and progressive in nature. It was also accompanied
dysplasia to carcinoma in situ to invasive squamous cell whitish discoloration of cornea and redness in right eye since
carcinoma. Depending upon the geographic location 1 month. Patient also gave history of small mass over bulbar
prevalence of SCC varies from 0.03-1.9 per million conjunctiva which was excised and sent for histopathological
population.2 Ocular Surface Squamous Neoplasia (OSSN) is examination 4 months back. The biopsy report showed
a multifactorial disease. Various environmental factors play presence of atypical proliferation of squamous epithelial cells
role in etiology and pathogenesis of SCC. Though it is rare with pleomorphism and few epithelial pearls suggestive of
in Indians, SCC is more common in equatorial countries and well differentiated type of squamous cell carcinoma (SCC)
in population with excessive sunlight exposure. ultraviolet for which some eyedrop was started but patient did not
rays, Human Papilloma Virus (HPV), mutation of P53 gene,
immunosuppression, smoking and exposure of petroleum complete the treatment and never appeared for follow-up.
products are some of the other risk factors. In early stage
patients are usually symptomless and unaware of the Investigation
disease. Approximately 95% of SCC lesions occur at the
limbus, where the most actively mitotic cells reside. There are On examination best corrected visual acuity of right eye was
three major clinical variants of SCC: papilliform, gelatinous, 1/60 and left eye was 6/18. On Slit Lamp Examination (SLE)
or leukoplakic. Abnormal or dysplastic epithelium have a there was mild congestion with a 2x2mm cystic mass over
diffuse, granular appearance, differentiating it from normal bulbar conjunctiva near the limbus nasally with cauliflower
epithelium.3 The abnormal squamous cells from limbus like growth in anterior chamber covering more than half
usually involve the cornea and have frosted appearance. of the anterior chamber and pupil as seen in (Figure 1).
Leukoplakic lesion may appear white and thickened due to On USG B Scan posterior segment was normal. The other
hyperkeratinisation of the lesion. Fluorescein, eye had grade II cataract with no sign of any mass with
lissamine green, or Rose Bengal are often used to highlight normal fundus examination. There was no enlargement of
the lesion.4 In SCC the abnormal cells extend through the preauricular or submandibular lymph nodes.
basement membrane into the conjunctival stroma, whereas
in intraepithelial neoplasia (CIN) the malignant cells are Management
confined to the surface epithelium. SCC has the potential to
penetrate the corneoscleral lamella into the anterior chamber 5-Fluorouracil 1% was administered topically 4 times
of the eye or can breach the orbital septum to invade the soft daily for 1 week followed by a drug holiday of 3 weeks.4
tissues of the orbit, sinuses, and the brain.5,6 These tumours cycles were given and followed. But there was no response
may metastasize via lymphatics or blood during the course to the treatment so the patient underwent enucleation
of disease. Owing to their possible aggressive behaviour, of the right eye after taking written consent. It was sent
conjunctival SCCs are therefore known to be sight and life for histopathological examination. The histopathological
threatening.6,7 Diagnosis can be made by clinical examination examination confirmed it to be well differentiated type of
with slit lamp biomicroscopy. However, overlap in clinical squamous cell carcinoma with infiltration of the anterior
features in OSSN and masqueraders like pterygium, chamber. It showed atypical proliferation of squamous
dyskeratosis, papilloma, scar tissue, corneal pannus, epithelial cells with anisonucleosis and aniscytosis. Nuclei
pyogenic granuloma, amelanotic melanoma, and sebaceous were large, pleomorphic and hyperchromatic with coarse
cell carcinoma can occasionally make diagnosis by clinical and clumpy chromatin. Few epithelial pearls were also
seen with keratinisation of cytoplasm. However, lymphatic
examination alone difficult. embolus or perineural invasion were not found in the
histopathology specimen.

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DJO Vol. 31, No. 2, October-December 2020

Figure 1: SLE showing a 2x2mm cystic mass over bulbar conjunctiva near References
the limbus nasally with cauliflower like growth in anterior chamber covering
1. Basti A, Macsai MS. Ocular surface squamous neoplasia:
more than half of the anterior chamber and pupil A review. Cornea 2003; 22:687-704. doi:10.1097/00003226-
200310000-00015
After enucleation patient did not turn for follow-up so
2. Sun EC, Fears TR, Goedert JJ. Epidemiology of squamous cell
post-operative results and complications could not be conjunctival cancer. Cancer Epidemiol Biomarkers Prev 1997;
6:73-7. doi: Published February 1997
documented. Discussion
3. Krachmer JH, Mannis MJ, Holland EJ. Cornea: Fundamentals,
SCC commonly presents as avascularised lesion in diagnosis and management. 2005. versión impresa ISSN 0365-
6691.
interpalpebral area mostly at the limbus. It is usually
4. Reidy JJ, Bouchard CS, Florakis GJ, et al. Basic and Clinical
symptomless and delay in treatment leads to metastasis to Science Course, 2011-2012. 2011:226–233.

intraocular, intraorbital and distant areas. Otherwise, it is a 5. Iliff WJ, Marback R, Green WR. Invasive squamous cell
carcinoma of the conjunctiva. Arch Ophthalmol. 1975;93 (2:119-
slow growing lesion with less metastatic potential. The best- 122). doi:10.1001/archopht.1975.01010020125005

established form of treatment is surgical excision with ‘‘wide 6. Shields CL, Shields JA. Tumors of the conjunctiva and cornea. Surv
Ophthalmol. 2004;49:3–24. doi:10.1016/j.survophthal.2003.10.008
margin, no touch’’ technique. Nevertheless, recurrences of
7. Walsh-Conway N, Conway RM. Plaque brachytherapy for the
these lesions are common after surgical excision, depending management of ocular surface malignancies with corneoscleral
invasion. Clin Exp Ophthalmol. 2009;37(6) :577–583. doi:
on the involvement of the surgical margins. Recurrence rates 10.1111/j.1442-9071.2009.02092.x.

following excision of SCC alone range from 15 to 52%, with 8. Erie JC, Campbell RJ, Liesegang TJ. Conjunctival and corneal
intraepithelial and invasive neoplasia. Ophthalmology 1986;
an average of 30%. Recurrence rate is 5% when the surgical 93:176-83. doi:10.1016/s0161-6420(86)33764-3

margins are free and 53% when the surgical margins are 9. Mehta, M; Fay, A (Winter 2009). "Squamous cell carcinoma of the
eyelid and conjunctiva". International ophthalmology clinics. 49
involved.8 Intra operative cryotherapy and brachytherapy, (1): 111–21. doi:10.1097/iio.0b013e3181928fb9

postoperative topical chemotherapy using Mitomycin C, Cite This Article as: Jayati Pandey, Perwez Khan,
Alok Ranjan A rare case report of Metastasis of Squamous
5-FU and interferon alfa-2b are adjunctive therapy to reduce cell Carcinoma of conjunctiva in anterior chamber Delhi J
Ophthalmology. 2020;31 (2):78-79
recurrences. Treatment of conjunctival SCC is usually
Acknowledgments: Nil
surgical excision followed by cryotherapy.9 After this
Conflict of interest: None
procedure, Conjunctival SCC can recur 8-40% of the time.9
Source of Funding: None
Radiation treatment, topical Mitomycin-C, and removal of
Date of Submission: 01 Sep 2019
the contents of the orbit, or exenteration, are other methods Date of Acceptance: 11 May 2020

of treatment.9 Close follow-up is recommended, because the Address for correspondence

average time to recurrence is 8–22 months.9 Alok Ranjan, Senior Resident
Department of Ophthalmology,
Conclusion G.S.V.M Medical College,
Kanpur, India.
In the above case though the patient reported early to the Email ID – [email protected]
doctor the patient did not comply with the treatments hence
even after the biopsy the metastasized to anterior chamber. Quick Response Code
Therefore, early diagnosis of the lesion with careful
examination slit lamp followed by proper investigation
is necessary to make correct diagnosis and start proper
treatment. Patient compliance with regular follow-ups
help in assessing the effect and complications of treatment.
Regular follow-up also helps in early diagnosis of recurrence
of lesion.

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DJO Vol. 31, No. 2, October-December 2020

Case Report

A Case Report of Coincidental Finding of Kayser-Fleischer Ring
in a Patient Seeking Treatment for Trauma

Senny Chapagain

Geta Eye Hospital, Kailali, Nepal

Abstract A 30-year-old male presented to the out-patient department with history of trauma to the left eye with his hand. On
examination, subconjunctival hemorrhage in left eye with bilateral Kayser-Fleischer ring and anterior sub capsular
cataract was observed. There were no coexisting neurologic or hepatic symptoms at presentation. However, the
patient had a history of jaundice one year back. We report an interesting case of Wilson disease presenting with
ocular features in the absence of neurologic symptoms. Early detection and treatment of Wilson disease is possible in
these cases with timely referral for systemic evaluation to prevent long-term complications.

Delhi J Ophthalmol 2020;31;80-81; Doi http://dx.doi.org/10.7869/djo.598
Keywords: Autosomal Recessive, Copper Metabolism, Descemet Membrane, Wilson's Disease, Kayser- Fleischer Ring, Anterior Capsular Cataract.

Introduction

Wilson disease (WD) is an inborn error of metabolism
resulting in excess copper deposition in the liver, kidney, and
other vital organs. It is an autosomal recessive disease.1 The
hepatic and neurological symptoms are the usual presenting
features.1 We report a case of WD presenting with ocular
features in the absence of systemic findings diagnosed on
incidental ocular examination for trauma to the eye.

Figure 1: Subconjunctiva l hemorrhage in the left eye

Figure 2: Kayser-Fleischer ring was observed in peripheral cornea. Figure 3: The Kayser-Fleischer ring and sunflower cataract was observed in
the left eye
Case report
showed congestion on left conjunctiva with sub conjunctival
A 30 year old man presented to our OPD with complaints of hemorrhage (Figure 1). There were characteristic copper-
redness in the left eye since 1day.He gave history of trauma colored Kayser-Fleischer (K-F) rings, encircling the
with his hand 1 day back. On examination, his best-corrected peripheral cornea, adjacent to the limbus in both eyes; the
visual acuity was 20/20 in both eyes. Slit-lamp examinations K-F ring was limited to the Descemet membrane (Figure
2). Bilateral yellowish-brown opacities in the anterior lens
capsule arranged as radiating spokes from the centre giving

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DJO Vol. 31, No. 2, October-December 2020

the appearance of “sunflower” was observed (Figure3). disease onset: Description of a pediatric case and literature review.
Hepat Mon. 12 (2012) 6233
Other ocular findings were normal. 4. M. Akil, J.A. Schwartz, D. Dutchak, V. Yuzbasiyan-Gurkan,
G.J. BrewerThe psychiatric presentations of Wilson's disease J
Discussion Neuropsychiatry Clin Neurosci, 3 (1991), pp. 377-382
5 A.B. Taly, S. Meenakshi-Sundaram, S. Sinha, H.S. Swamy, G.R.
Wilsons disease is a disorder of copper metabolism which ArunodayaWilson disease: description of 282 patients evaluated
over 3 decadesMedicine (Baltimore), 86 (2007), pp. 112-121
is inherited as an autosomal recessive trait. It is caused by 6. C. A. Sullivan, A. Chopdar, G.A. Shun-ShinDense Kayser-
Fleischer ring in asymptomatic Wilson's disease (hepatolenticular
the impaired function of P-type adenosine triphosphatase degeneration) Br J Ophthalmol, 86 (2002), p. 114
7 D.O. Wiebers, R.W. Hollenhorst, N.P. GoldsteinThe ophthalmologic
(ATPase), which is encoded by the ATP7B gene located on manifestations of Wilson's disease Mayo Clin Proc, 52 (1977), pp.
409-416
chromosome 13q14.2 Mutation of the ATP7B gene prevents 8 J.C. SuvarnaKayser-Fleischer ringJ Postgrad Med, 54 (2008), pp.
238-240
the transport protein from functioning properly, due to 9 M. Fenu, M. Liggi, E. Demelia, O. Sorbello, A. Civolani, L.
DemeliaKayser-Fleischer ring in Wilson's disease: a cohort study
which excess of copper accumulate in the liver, brain, Eur J Intern Med, 23 (2012), pp. e150-e156
10. B. Esmaeli, M.A. Burnstine, C.L. Martonyi, A. Sugar, V. Johnson,
kidneys, skeletal system and basal ganglia of the brain. The G.J. BrewerRegression of Kayser-Fleischer rings during oral zinc
therapy: correlation with systemic manifestations of Wilson's
accumulated copper results in liver cirrhosis, renal tubular disease Cornea, 15 (1996), pp. 582-588

damage, and parkinsonism like defect of motor function. Cite This Article as: , S. A case Report of Coincidental finding
of Kayser-Fleischer Ring in a patient Seeking Treatment for
In a study by (quote the first author’s name here) the mean Trauma. Delhi J Ophthalmol 2020;31 (2) ;80-81.

age of onset of symptoms was 13.5 years (range: 3-44 years) Acknowledgments: Nil

with the mean age at presentation of 15.6 years (range: 3-45 Conflict of interest: None declared

years) and the mean delay in diagnosis of 2.0 years (0.08-30 Source of Funding: None

years).3 Date of Submission: 20th Jan 2020
Date of Acceptance: 14th May 2020
One-third cases of WD present with hepato-biliary
Address for correspondence
symptoms, another third with neurologic symptoms, and Senny Chapagain MD

others with psychiatric and behavioral features.4 Similarly Geta eye hospital, Dhangadi.
Kailali, Nepal
another study revealed that the neurologic deficits (69.1%) [email protected]

was the most common presenting feature followed by Quick Response Code

hepatic abnormalities (14.9%), hepato-neurologic deficits

(3.5%), psychiatric symptoms(2.4%), and osseo-muscular

dysfunction (2.1%); only 5.3% were presymptomatic.5 K-F

rings are observed in association with systemic involvement

of WD. This study also demonstrated that K-F ring was seen

in 100% of the cases with neurologic involvement, 86%;

of the cases with hepatic involvements, and in 59% of the

presymptomatic patients.

In our case, the patient presented following ocular trauma.

KF ring and sunflower cataract was diagnosed coincidently

in the absnece of neurologic or hepatic abnormalities. K-F

ring and sunflower cataract are indicators of advanced stage

of the disease and patients with K-F rings generally have

neurologic manifestations. Sullivan et al6 and Goel et al have

previously reported similar cases of WD presenting with

ocular features.

K-F ring and sunflower cataract usually develops as a result

of excess copper accumulation in these tissues. It is seen in

cases of WD but can also be seen in other cases like cholestasis,

primary biliary cirrhosis, and cryptogenic cirrhosis.8 Serum

ceruloplasmin and bilirubin levels can help to arrive at an

appropriate diagnoses.9,10

In conclusion, patients with WD can present with ocular

symptoms. Early diagnosis of asymptomatic WD with

only ocular manifestations and early referral to physician

can aid in proper diagnosis and initiation of chelation and

zinc therapy preventing the possible long term systemic

complications. References

1. Sternlieb Perspectives on Wilson's disease Hepatology, 12 (1990),
pp. 1234-1239

2. S. Vrabelova, O. Letocha, M. Borsky, L. KozakMutation analysis
of the ATP7B gene and genotype/phenotype correlation in 227
patients with Wilson disease Mol Genet Metab, 86 (2005), pp. 277
285

3. Di Stefano V, Lionetti E, Rotolo N, La Rosa M, Leonardi S.
Hypercalciuria and nephrocalcinosis as early feature of Wilson

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DJO Vol. 31, No. 2, October-December 2020

Case Report

Ocular Manifestation As Earliest Presentation Of Non-Hodgkin’s
Lymphoma, Mimicking Multiple Chalazia: A Rare Case Report

Pallabi Ray Chaudhuri,1 Uttam Biswas,2 Soumya Ray,3 Koushik bose,4 Avik Dey Sarkar,5 Asim Kumar Dey,6

1,3,6 Department of Ophthalmology, Burdwan Medical College, Burdwan,West Bengal, India.
2 Department of Medicine, Burdwan Medical College, Burdwan, West Bengal, India.
4 Department of Pathology, Burdwan Medical College, Burdwan, West Bengal, India.

5Department of Ophthalmology, Midnapore Medical College, Midnapore, West Bengal, India.Bengal, India.

Abstract Primary orbital Non-Hodgkin’s lymphoma (NHL) is very rare. This 40 year old female patient presented with small multiple
smooth swellings on upper and lower conjunctival fornix and in subsequent visits she develops swelling arising from both
side lacrimal sac location. MRI brain and orbit suggested multiple oval shaped lesions noted at retro-bulbar , medial
and lateral canthus of both eyes and periorbital area without any bony destruction. Biopsy confirmed it to be a case of
primary non-Hodgkin’s lymphoma. She was given 6 cycles of chemotherapy with CHOP. The patient is now asymptomatic
2 months after the last cycle of the chemotherapy.

Delhi J Ophthalmol 2020;31;82-84; Doi http://dx.doi.org/10.7869/djo.599

Keywords: Orbital; Primary; Non-Hodgkin’s lymphoma (NHL); Chemotherapy.

Introduction

Lymphomas are malignant neoplasm of lymphoreticular Figure 1: (A,B,C):Patient before treatment.
system and mainly involve lymph-nodes, spleen and other
non-haemopoietic tissues. Eighty percent of lymphomas are and oral antibiotics with no improvement at all. During
B-cell type, while 14% are T-cell type, with natural killer subsequent visits she developed swelling in both of her
type (NK) forms only 6%..1 NHL mostly arise in the lymph lacrimal sac region[Figure-1(A)]. All the swelling were
nodes termed as nodal NHL (N-NHL), but approximately painless, gradually increasing in size. Her vision, intraocular
25-40% arise in tissues other than the lymph node, and pressure, fundus findings and pupillary reactions were
therefore termed extra nodal lymphomas (EN-NHL).2 The within normal limits bilaterally. Ocular movements were
definition of EN-NHL is controversial especially in patients full and symmetrical in both eyes.
where both nodal and extra nodal sites are involved.3 The There was no lymphadenopathy or organomegaly found.
common extranodal sites involved are gastrointestinal tract, Neither mediastinal dullness nor any features of superior
upper aerodigestive tract, bones, and spine while unusual venacaval obstruction was noted. There was no cranial nerve
sites with involvement less than 3% are breast, central involvement. Peripheral blood smear showed no abnormal
nervous system, testis, lung and skin.4 Primary orbital Non- cells. Haemoglobin was 9.3 g/dl, serum LDH was 677 U/l,
Hodgkin’s Lymphoma is a rare presentation of extranodal Urea level 15 mg/dl , Creatinine 0.8 mg/dl. Other routine
non Hodgkin’s lymphoma accounting for less than one laboratory tests like blood glucose, liver function test, uric
percent of NHL.5 It affects primarily the lacrimal gland, acid, calcium, chest X-ray, echocardiography, and upper
conjunctiva, eyelid orbit and ocular adnexa.6 The diagnosis gastrointestinal endoscopy were normal. HIV serology
is difficult and often delayed, because it can present with a was nonreactive. She was further investigated by Contrast
wide variety of manifestations that can mimic many ocular enhanced MRI Scan of Orbit along with paranasal sinus (PNS)
conditions. Non-Hodgkin’s lymphoma is a heterogeneous
group of neoplasm both in their natural history and response
to treatment. Here we report a rare case of Primary- NHL

involving both eyes orbit and ocular adnexa.

Presentation of the Case

A 40 year old female presented with foreign body sensation
in both eyes with increased lacrimation, weight loss, night
sweats and intermittent restlessness with palpitation. There
was no history of fever, cough, haemoptysis ,pain abdomen,
lump and bumps anywhere . There was no past history of
tuberculosis or contact with tuberculosis and neither she
was immunocompromised nor on any immunosuppressive
drugs. There was no prior history of exposure to radiation.
On general examination, she had mild pallor. On ocular
examination, multiple salmon pink colored small swelling
was seen in superior and inferior conjunctival fornix in both
the eyes[Figure-1(B,C)] and initially treated with topical

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DJO Vol. 31, No. 2, October-December 2020

and Brain which revealed multiple oval shaped lesions noted

at retro-bulbar and medial and lateral canthus of both eyes

and periorbital area with patchy contrast enhancement "with

true diffusion restriction" suggestive of lymphoproliferative

disorder (Figure-3). No space occupying lesion was seen

and no evidence of any pseudotumor was noted . Para nasal

sinuses were within normal limit. She was provisionally

diagnosed as a case of Primary Orbital lymphoma. The

incisional biopsy tissue sample was taken from swelling and

sent for histopathological examination, which revealed Non-

Hodgkin’s lymphoma of diffuse large B cell type (Figure-4).

She had recieved with 6 cycles of chemotherapy with CHOP

(considering her height 4’ 11”, body weight 50kgs, body

surface area 1.44 m2) ;Inj. Cyclophosphamide (750mg/m2 =

1080mg), Inj Doxorubicin (40mg/m2 = 60mg), Inj. Vincristine

(1.4mg/m2 = 2mg) and Tablet Prednisolone (100 mg). She

had been asymptomatic thereafter and no further recurrence

noted on 2 months follow-up and she is still on follow up

(Figure 2). Discussion

Primary Non-Hodgkin’s lymphoma (NHL) of the orbit is a Figure 4: Photomicrograph of histopathological analysis of excisional biopsy
specimen from orbital masses showing large atypical lymphoid cells with
rare presentation, representing 8%-10% of extranodal NHL
and only 1% of all NHL.[5] Generally, it has an indolent nuclei having prominent nucleoli suggestive of NHL. H&E stain, [40 x]

course. Orbital and adnexal lymphoma is associated with out systemic lymphoma. Orbital lymphoma is a lymphoma
occurring in the conjunctiva, lacrimal gland, eyelid and
systemic lymphoma in 30-35% of cases [5]. Hence, all patients ocular musculature. There is another variety known as
primary vitreo-retinal lymphoma (PVRL) which is also very
with ocular lymphoma should have a complete workup to rule rare and 90% of these patients will eventually develop CNS
lymphoma and PVRL is best considered as a subset of primary
Figure 2: Patient after 2 cycle of chemotherapy CNS lymphoma. The usual presentation of PVRL is blurred
vision with non-resolving uveitis and vitritis.7 So NHL in
Figure 3: (1,2,3,4) MRI of Brain,Orbit and PNS of the patient eye can be manifested as conjunctival mass, orbital mass,
(Detail describe in the text) choroidal infiltration with secondary uveitis and infiltrative
optic neuropathy. It may be of following histological types:
mucosa associated lymphoid tissue (MALT) histology (57%),
follicular lymphomas (19%), diffuse large B-cell lymphomas
(DLCL), mantle cell lymphomas, B-cell chronic lymphocytic
leukaemia, peripheral T-cell lymphoma, and natural killer
cell lymphoma.8 Out of which occular adnexal mucosa-
associated lymphoid tissue (MALT) lymphoma (57%) is the
commonest one, and it’s usually associated with Chlamydia
psittaci.9 Majority of the orbital lymphomas are of low grade
variety (84%) and only 16% are of high-grade histology.10
Orbital lymphoma may be unilateral or bilateral and up
to 20% bilateral presentation is noted. A recent study has
shown that ocular lymphoma is more prevalent in women
than men.11
It commonly presents with ocular inflammation and
swellings and is really a diagnostic challenge for the
ophthalmologist. Differential diagnosis of the most common
and important periorbital lesions includes multiple chalazia,
chronic dacryocystitis, granuloma of orbit and adnexa,
lymphangioma,NHL of orbit and adnexa and metastatic
deposits. In our case MRI Orbit and brain was suggestive
of lympho-proliferative disorder at retro-bulbar medial
and lateral canthus and subsequent histopathological
examination proven it to be ocular NHL . But further typing
by immune- histochemical study can not be done due to

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DJO Vol. 31, No. 2, October-December 2020

limitation of resources. Treatment options for ocular NHL clinic-pathologic features and outcomes in comparison with nodal
Non-Hodgkin’s lymphoma. Asian Pac J Cancer Prev 9: 453-458.
include radiotherapy, chemotherapy, excisional biopsy and 5. Coupland SE, Hummel M, Stien H. Ocular adnexal lymphomas:
Five case presentation and a review of literature. Surv Ophthalmol.
cryotherapy. Immunotherapy includes anti- CD20 antibody, 2002; 47: 470–90.
6. Freeman C, Berg JW, Cutler SJ. Occurrence and prognosis of
even with chemotherapy, and radio immunotherapy for extranodal lymphomas. Cancer. 1972; 29: 252–60.
7 Chan CC,Ruben stein JL ,Coupland AC et.al .Primary vetreoretinal
patients with CD20 positive NHL.12 the survival rate is lymphoma : a report from an International Primary Central
Nurvous System LymphomaCooaborative Group symposium.
approximately 60% after 5 years. MALT lymphoma has Oncologist.2011;16(11):1589-99.
8 Parikshit M, Ayan B, Yogiraj R, Mehebubar R, Prosad GR Primary
the best prognosis, DLCL prognosis can be improved by Non-Hodgkin’s Orbital lymphoma of diffuse large B-cell type: a
rare presentation. Bangladesh Journal of Medical Science Vol. 15
early prompt diagnosis and combination chemotherapy. No. 04 October’16.
9 Ferreri AJ, Guidoboni M, Ponzoni M et-al. Evidence for an
The role of radiotherapy in DLCL is unclear. Combination association between Chlamydia psittaci and ocular adnexal
lymphomas. J. Natl. Cancer Inst. 2004; 96 (8):586-94
chemotherapy with CHOP (cyclophosphamide, doxorubicin, 10 Bessel EM, Henk JM, Wright JE, Whitelocke RA. Orbital and
conjunctival lymphoma: Treatment and prognosis. Radither
vincristine and prednisolone) is quite efficacious, while Oncol. 1988; 13: 237–44.
11 Ahmed, S; Shahid, RK; Sison, CP; Fuchs, A; Mehrotra, B “Orbital
addition of intravenous rituximab (anti CD 20 monoclonal lymphomas: a clinicopathologic study of a rare disease”. The
American journal of the medical sciences (February 2006).;331 (2):
antibody) in the regimen helps in rapid remission with good 79–83.
12 Parul S, Singh A, Pandey H, Chauhan AK, Tripti S, et al. (2011)
results.13,14 So, total or subtotal excision of the mass followed An Atypical Ocular Presentation of Multifocal Extranodal Non
Hodgkin’s Lymphoma: A Case Report. J Clinic Experiment
by radio-therapy and or chemotherapy has a better outcome Ophthalmol 2:121.
13 Benabid L, Desablens B, Defossez T, Malthieu D, Milazzo S, Turut
in patients with large mass However, radiation exposure P. [New treatment for orbital non- Hodgkin’s lymphoma: 2 cases
treated with rituximab]. J Fr Ophtalmol. Sep 2005; 28 (7): 769-71.
predisposes to the development of cataracts after 3 – 8 years 14. Savino G, Battendieri R, Gari M, Caputo CG, Laurenti L, Blasi
MA. Long-term outcomes of primary ocular adnexal lymphoma
though The role of radiotherapy in DLCL is unclear. So, from treatment with intraorbital rituximab injections. J Cancer Res Clin
Oncol. Apr 27 2013.
the literature we can conclude that if CD20 is positive then
Cite This Article as: Pallabi Ray Chaudhuri, Uttam Biswas,
R-CHOP is most efficacious but NHL without CD20 positive
Soumya Ray, Koushik bose, Avik Dey Sarkar, Asim Kumar Dey.
patients treatment should be initiated with CHOP regimen.
Ocular Manifestation As Earliest Presentation Of Non-Hodgkin’s
So she was treated with CHOP regimen and responding Lymphoma, Mimicking Multiple Chalazia: A Rare Case Report Delhi J
Ophthalmology. 2020;31 (2): 82-84
well with treatment .The size of the swellings reduced
Acknowledgments: Nil
significantly after second cycle of chemotherapy (Figure-2)
Conflict of interest: None declared
and she had significant improvement of symptoms. The
Source of Funding: None
patient is now asymptomatic even after two months of last
Date of Submission: 31 Jan 2020
dose of chemo-therapy and is on follow up. Date of Acceptance: 11 May 2020

Conclusion Address for correspondence

Lymphoma can occur in the orbit without any systemic Pallabi Ray Chaudhuri MBBS, MS

manifestations. A palpable painless mass of an eye (Ophthalmology) Junior Resident

particularly in elderly female should be suspected as Department of ophthalmology,
Burdwan MedicalCollege & Hospital,
lymphoma. Because early diagnosis of an orbital lymphoma Madurdaha, Kolkata, India.
Email: [email protected]
before any bony destruction starts, will improve the
Quick Response Code
prognosis of the patient. R-CHOP chemotherapy regimen

is better than CHOP regimen if patient is CD20 positive

without any recurrence at follow-up.

Key Messages

Primary Non-Hodgkin’s lymphoma of the orbit is rare.

Ocular Lymphomas presents as a wide range of clinical

manifestation, therefore diagnosis can be challenging. It

requires a high degree of clinical suspicion for early diagnosis

and differential diagnosis includes different infectious and

non-infectious etiologies. It can occur in orbit without any

other systemic involvement. If it can be diagnosed early

without other nodal or extranodal involvement then treated

successfully with CHOP chemotherapy with excellent

prognosis. Referrence

1. Fitzpatrick PJ, Macko S. Lymphoreticular tumors of the orbit. Int J
Radiat Oncol Biol Physics. 1984; 10: 333–40.

2. Zucca E, Roggero E, Bertoni F, Cavalli F (1997) Primary extranodal
Non- Hodgkin’s lymphomas, part 1: Gastrointestinal. Ann Oncol
Ann Oncol 8: 727- 737.

3 Krol AD, le Cessie S, Snijder S, Kluin-Nelemans JC, Kluin PM, et
al. (2003) Primary extranodal Non-Hodgkin’s lymphoma (NHL):
the impact of alternative definitions tested in the Comprehensive
Cancer Centre West population-based NHL registry. Ann Oncol
14: 131-139.

4. Lal A, Bhurgri Y, Vaziri I, Rizvi NB, Sadaf A, et al. (2008)
ExtranodalNon- Hodgkin’s lymphomas- a retrospective review of

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DJO Vol. 31, No. 2, October-December 2020

Case Report

Bronchodilator Nebulization – A Rare Presentation of Bilateral
Acute Angle Closure Glaucoma

Divya Deepthi Syamala, Malleswari Medikonda

Sankara Eye Hospital, Vijayawada –Guntur Expressway, Pedakakani, Guntur, Andhra Pradesh, India.

Abstract Bronchodilator nebulization is one of the most commonly administered treatment for an acute attack of reactive
airway disease. Development of acute angle closure glaucoma following nebulization therapy is a rare occurrence.
We report a case of acute angle closure of both eyes in a 54 year old gentleman shortly after receiving therapy with
inhaled salbutamol and ipratropium. This patient presented to our tertiary care eye hospital and was immediately
treated with medical management and laser iridotomy. This case report highlights this rare but possible side effect
of inhaled bronchodilator therapy. Health care providers need to be aware of this uncommon adverse effect and
appropriate preventive measures such as identifying at risk individuals, usage of protective eye-wear, etc should
be practiced.


Delhi J Ophthalmol 2020;31;85-89; Doi http://dx.doi.org/10.7869/djo.600

Keywords: Acute Angle Closure, Salbutamol, Ipratropium, Glaucoma

Introduction Figure 1a: Anterior segment of RE showing congestion and mid-dilated pupil

Acute angle closure glaucoma (AACG) affects about 0.1%
of people older than 40 years and the risk increases further
with advancing age1. Precipitation of AACG with use of
inhalational agents like alpha-adrenergic drugs is well
documented in literature especially in the elderly. The
symptoms usually start within few hours to up to 9 days
after exposure to inhalational therapy. It usually manifests
with sudden decrease in vision, photophobia and headache
in the distribution of ipsilateral trigeminal division of
ophthalmic nerve.
It is crucial to have a high index of suspicion to promptly
recognise symptoms and diagnose AACG in these patients to
prevent permanent damage. As per existing evidence, there
seems to be a synergistic effect to combined bronchodilator
therapy (salbutamol and ipratropium) in precipitating an
acute attack of AACG.2

Case Report Figure 1b: Anterior segment of LE showing congestion and mid-dilated pupil

A 54 year old gentleman presented with headache, edema, extremely shallow anterior chamber (Figure 2),
pain and blurring of vision in both eyes especially the fixed and mid-dilated pupils (Figure 1). The Intraocular
left eye beginning 8 hours earlier. Past medical history pressure (IOP) was 42 mmHg in RE and 40 mmHg in LE.
was significant for rheumatic mitral valve disease with
recent mitral valve replacement few weeks ago. He was
on treatment with acitrom, amiodarone, verapamil,
furosemide, spironolactone, and pantoprazole orally. One
day prior to the presentation to ophthalmology department,
he had developed an episode of acute breathlessness for
which he received nebulization with ipratropium bromide
and salbutamol. Patient developed acute ocular pain and
blurring of vision in left eye followed by right eye within 8
hours of receiving the nebulization.
On presentation to the emergency department, patient
was conscious, oriented and in severe pain. Systemic
examination was normal except for tachycardia secondary
to pain. On Ocular examination, his visual acuity was
assessed as counting fingers in both eyes. Both eyes revealed
moderate conjunctival congestion, microcystic corneal

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DJO Vol. 31, No. 2, October-December 2020

Figure 2a: Van Herick’s RE showing Grade 1 Figure 2b: Van Herick’s LE showing Grade 1

Figure 3a: Gonioscopic images RE showing closed angles(A=superior angle,B=nasal angle,C=inferior angle,D=temporal angle)

Figure 3b: Gonioscopic images LE showing closed angles(A=superior angle,B=temporal angle,C=inferior angle,D=nasal angle)

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DJO Vol. 31, No. 2, October-December 2020

Figure 4a: Ultrasound Biomicroscopy of LE pre PI showing shallow AC Figure:4b: Ultrasound Biomicroscopy of LE post PI showing deepening of AC

Gonioscopic examination of both eyes revealed 360° closed RE and 14mmHg in LE, patent iridotomies in both eyes with
angles,(Figure 3a &3b) thus confirming the diagnosis of acute deepened anterior chambers(Figure 6) and his unaided visual
angle closure glaucoma in both eyes. Patient was treated acuity improved to 6/12 in both eyes. All ocular hypotensive
with prednisolone 1 % eye drops QID for inflammation, medications were stopped and topical steroids tapered over
oral glycerol 40 ML, acetazolamide BD, topical brimonidine 3 weeks period. His fundus examination in both eyes was
0.2% eye drops TID, brinzolamide 1% TID and pilocarpine normal except for pallor of the optic discs due to raised
2% QID. Two hours after the treatment and partial clearing intraocular pressure at the time of acute attack(Figure 5).
of corneas in both eyes, Peripheral Iridotomy (PI) was
performed with Nd YAG laser in both eyes. This decreased Discussion
the IOP to 22 mm Hg in Right eye and16mm Hg in Left eye
with immediate symptomatic relief. Patient was prescribed AACG is one of the commonest emergencies faced in clinical
prednisolone acetate 1% eye drops 4 times per day in both ophthalmology. It may cause blindness if not promptly
eyes and advised to continue topical and systemic ocular diagnosed and managed.Acute angle closure attack generally
hypotensive treatment and review after 3 days. Three day occurs following pupillary block and can also occur in
follow-up examination demonstrated IOP of 12mm Hg in association with ciliary body position and lens thickening.3
Many medications have been implicated in triggering AACG

Figure 5a: Fundus photo showing disc pallor in RE Figure 5b: Fundus photo showing disc pallor in LE

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DJO Vol. 31, No. 2, October-December 2020

Figure 6a: Anterior segment of RE post PI showing deepened anterior Figure 6b: Anterior segment of LE post PI showing deepened anterior chamber
and PI
chamber and PI
aware that they are predisposed because of presence of
like adrenergic, cholinergic, anticholinergic, antihistaminic, innately narrow iridocorneal angles. If at all it is known
antidepressant and antispasmodic agents.3,4,5 that a person has innately narrow angle, then further
One of the frequently used bronchodilator drug for evaluation with gonioscopy is warranted and consultation
obstructive airway disease is salbutamol (beta2 agonist). with an ophthalmologist should be sought for appropriate
Stimulation of the sympathetic pathway due to topical management.
absorption causes pupillary dilatation precipitating an acute There are recommendations regarding assessing probability
attack of ACG. Similar phenomenon has also been reported of AACG in patients who need inhalational bronchodilators.
with usage of ipratropium which is an anticholinergic drug. The possibility of precipitating an attack of AACG should
The combined use of beta agonist and anticholinergic drugs always be kept in mind when administering nebulized
has been reported to increase the chances of AACG.6,7,8 medicine to elderly patients. Previous history of AACG or
Corneal absorption of salbutamol during nebulization has symptoms such as blurred vision, red eye, nausea, unilateral
been hypothesised by Kalra and Bone to result in increased headache and experiencing coloured halos should be
intraocular pressure (IOP) and angle narrowing. This may elicited. It is advisable that an ophthalmologist consultation
result in increased aqueous humor secretion secondary is sought for patients deemed to be at risk for AACG before
to agonist action on beta2 receptors in the ciliary body. initiating on bronchodilator therapy. This may be feasible in
Similarly, AACG can be precipitated by antagonist action selected hospitalized settings however the practicality of this
of ipratropium on the parasympathetic pathway. In fact, approach for an acutely sick patient in the emergency room
all the patients with narrow angles in their series who were has been questioned.
exposed to inhalation treatment with combined salbutamol One practical approach is to avoid simultaneous
and ipratropium, had a documented increase in IOP. About nebulization of adrenergic and anticholinergic drugs at the
half of these patients developed transient angle closure. It same time. However the ideal interval of time gap between
was observed that this increase in IOP did not happen in nebulization of these two classes of drugs is not clearly
patients wearing protective eyewear such as goggles. This established. The rationale for combined use of ipratropium
suggests that the changes in IOP and angle probably were and salbutamol is the possible synergism between the 2
caused by topical absorption. classes of drugs.9 It has been advised that at risk patients be
treated prophylactically with topical miotics (1% pilocarpine
Risk factors hydrochloride) before using inhaled bronchodilator drugs.10
Glaucoma medications should be continued in known
Common risk factors implicated for AACG are elderly patients of glaucoma who are on treatment with inhalational
age, female sex, Asian ethnicity, strong family history bronchodilator therapy. Further, patients should be advised
of similar eye disease and hypermetropia. A few innate against rubbing their eyes after the nebulization to prevent
anatomical features may also predispose to the risk such auto-inoculation.
as a thick crystalline lens, plateau iris configuration and All patients planned for inhalation with anti-cholinergic
narrow irido-corneal angles. A significant number of people
who develop AACG due to pupillary block are seldom

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DJO Vol. 31, No. 2, October-December 2020

and alpha-adrenergic drugs should be educated regarding Cite This Article as: Divya Deepthi Syamala, Malleswari
the signs and symptoms of AACG so that an impending Medikonda Bronchodilator nebulization – a rare presentation of
attack can be promptly identified and averted by early Bilateral Acute angle closure glaucoma Delhi J Ophthalmology.
intervention. Apart from patient education, it is also 2020;31 (2):85-89
imperative that doctors and other health care professionals Acknowledgments: Nil
be aware of the possibility of this complication secondary to Conflict of interest: None
nebulization therapy. Other practical measures that reduce Source of Funding: None
ocular deposition of nebulized medicine are using protective Date of Submission: 14th March,2020
eyewear, using properly fitting and positioned face masks Date of Acceptance: 17th May,2020
and hand-held nebulizers.
Address for correspondence
Conclusion Divya Deepthi Syamala M.B.B.S,

The risk of precipitating AACG with usage of nebulized M.S(Ophth)
drugs such as salbutamol and ipratropium should always
be kept in mind while treating patients with bronchospasm. Department: Anterior Segment and
Necessary precautions should always be taken to prevent Glaucoma Institution: Sankara Eye
direct drug contact with eyes during nebulization. Hospital, Guntur, Andhra Pradesh,
India.
References Email : [email protected]

1. Duke-Elder S, Jay B: Diseases of the lens and Vitreous: Quick Response Code
Glaucoma and Hypotony. St Louis: Mosby, 1969, p 392-
398. (System of Ophthalmology;v 11).

2. Shah P, Dhurjon L, Metcalfe T, et al: Acute angle closure
glaucoma associated with nebulized ipratropium
bromide and salbutamol. BMJ 1992;304:40-41

3. Lai J, Gangwani R (2012) Medication-induced acute
angle closure attack. Hong Kong Med J 18:1139–1145

4. Lachkar Y, Bouassida W (2007) Drug-induced acute
angle closure glaucoma. Curr Opin Ophthalmol 18:129–
133

5. Tripathi R, Tripathi B, Haggerty C (2003) Drug-induced
glaucomas: mechanism and management. Drug Saf
26:749–767

6. Hall SK. Acute angle-closure glaucoma as a complication
of combined beta-agonist and ipratropium bromide
therapy in the emergency department. Ann Emerg Med
1994;23:884 – 887.

7. Mulpeter KM, Walsh JB, O’Connor M,et al. Ocular
hazards of nebulized bronchodilators. Postgrad Med J
1992;68: 132–133.

8. Kalra L, Bone MF. The effect of nebulized bronchodilator
therapy on intraocular pressures in patients with
glaucoma. Chest 1988;93:739 –741.

9. Gross NJ. Ipratropium bromide. N Engl J Med
1988;319:486-492.

10. Berdy GJ, Berdy SS, Odin LS, et al: Angle closure
glaucoma precipitated by aerosolized atropine. Arch
Intern Med 1991;151:1658-1660.

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DJO Vol. 31, No. 2, October-December 2020

Abstract Case Report

Torpedo Maculopathy with Satellite Lesion

Sonia Singh, N.S.Muralidhar, Hemanth Murthy

Retina Institute of Karnataka, Chamrajpet, Bengaluru, Karnataka, India.

Torpedo maculopathy is a rare congenital abnormality of the retinal pigment epithelium (RPE). It is
characterized by unilateral, solitary, well circumscribed, hypopigmented, horizontally oval ‘torpedo’ shaped
chorioretinal lesion. It should be considered as differential diagnosis for macular hypopigmented lesions.
Considered as solitary, there have been rare case reports of double torpedo and satellite torpedo lesions.
Here we report a case of Torpedo maculopathy with satellite lesion with its clinical features and Optical
Coherence Tomography(OCT) findings.

Delhi J Ophthalmol 2020;31;90-92; Doi http://dx.doi.org/10.7869/djo.601
Keywords: Torpedo Maculopathy, Satellite Lesion, Choroidal Excavation, Optical Coherence Tomography

Introduction Case Report

Torpedo maculopathy is a rare congenital abnormality of the A 31 year old male came to our Retina clinic for opinion
retinal pigment epithelium. The diagnosis of this entity is regarding macular scar in the left eye. He was using glasses
based on the clinical findings supported by investigations since 15 years. His BCVA was 6/12 in the right eye and 6/18
like OCT, Fundus autofluorescence and sometimes in the left eye. Refraction showed -5.50 DS in right eye and
associated VF defect. Its first description dates back to -7.0 DS in left eye. Anterior segment was unremarkable
1992 when Roseman and Gass described a solitary, sharply in both the eyes. Dilated Fundus evaluation revealed
circumscribed, oval, pinkish-white, placoid lesion along the a flat, horizontally oval, well defined hypopigmented
horizontal raphe with a wedge-shaped "tail" at the level of chorioretinal lesion in temporal aspect of macula with
the retinal pigment epithelium in the macula in a 12 year old the narrow fraying tail temporally (Figure 1). The lesion
boy, which was termed as a solitary ‘hypo pigmented nevus extended till the centre of the macula. The temporal end of
of the RPE’.1 This kind of lesion was later termed as ‘Torpedo the lesion showed hyperpigmentation. There was another
Maculopathy’ by Daily because of its peculiar shape.2 The smaller hypopigmented satellite lesion temporal to it. Rest
exact aetiology and pathogenesis of these lesions is still not of the peripheral retinal examination as well as the retinal
known. Although considered as rare, asymptomatic, non- examination of the right eye did not reveal any abnormality.
progressive and benign; torpedo lesions may be associated OCT of the macula revealed thinning of the outer nuclear
with Choroidal Neovascular Membrane (CNVM). Hence layer, attenuation of the ellipsoid zone and RPE with
they should be kept in mind as the differential diagnosis of underlying hyper reflectivity of the choroid (Figure 2). The
well-defined hypo pigmented macular lesions. scan over the pigmented part of the lesion showed RPE

Figure 1: Right eye fundus image showing normal fundus. B. Left eye fundus image showing Torpedo maculopathy with satellite lesion

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DJO Vol. 31, No. 2, October-December 2020

thickening with mild choroidal excavation in addition to Figure 2: OCT of the macula showing thinning of the outer nuclear layer,
the rest of the features. The satellite lesion revealed early attenuation of the ellipsoid zone and RPE with underlying hyper reflectivity
disorganization of the ellipsoid zone. of the choroid. The scan over the pigmented part of the lesion shows RPE

Discussion thickening with mild choroidal excavation.

Torpedo maculopathy lesions are classically described as The diagnosis of this condition is mainly clinical with
asymptomatic unilateral, solitary, hypopigmented lesions. adjuvant investigations like OCT and FAF. Fluorescein
Most of the times they are detected on routine clinical Angiography can be done in case a CNVM is suspected. The
examination. These ‘Torpedoes’ are usually seen temporal to current case shows similarities in terms of clinical features
the macula, but atypical locations have also been reported 3,4 and imaging findings of Torpedo lesions. This case report
. Irrespective of the location of the lesion, the tip of the lesion however adds to the previously reported rare instances
always points towards the optic disc. Satellite lesion has been of satellite lesion and foveal involvement of torpedo
reported by very few authors4,5.Visual acuity is not affected maculopathy. Although classically described as solitary,
unless the lesion extends to fovea. Differential diagnosis to our case report adds to the previously reported few cases of
be considered are Congenital Hypertrophy of the Retinal satellite lesion associated with Torpedo maculopathy which
Pigment Epithelium(CHRPE), Gardner syndrome, choroidal should be considered while making the clinical diagnosis of
naevus, chorioretinal scars(toxoplasmosis, trauma), Torpedo maculopathy. These lesions should be followed up
melanoma etc. regularly in view of possibility of development of CNVM.

The exact aetiology of these lesions is not known. Various Declaration of patient consent
hypothesis have been postulated that include persistent
defect in the development of RPE in the fetal temporal The authors certify that they have obtained all appropriate
bulge,6 abnormal choroidal vasculature,3,7 developmental patient consent forms. In the form the patient has given his
defect in the nerve fiber layer at the horizontal raphe,8 and
malformation of the emissary canal of the long posterior
ciliary artery and nerve.9

Fundus Autofluorescence(FAF) may reveal hypo-
autofluorescence, hyperautofluorescent boundaries , or a
mixture of hyper and hypo autofluorescence. OCT in this
case revealed thinning of the outer nuclear layer, ellipsoid
zone, and RPE with underlying hyper reflectivity of the
choroid. The area corresponding to the pigmented part of
the lesion showed mild choroidal excavation. There was
no subretinal cavitation or cleft which has been reported in
some cases. Wang et al have classified these lesions into Type
1 and 2 where Type 2 lesions show outer retinal cavitation
with or without inner choroidal excavation which is absent
in Type 1 lesions10. Many times these lesions may show
corresponding scotoma on visual field analysis.10,11 There
have been reports of CNVM associated with Torpedo
maculopathy.12,13,14

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DJO Vol. 31, No. 2, October-December 2020

consent for his images and other clinical information to be maculopathy.Clin Exp Optom2017;100:563–568.
reported in the journal. The patient understands that his 12 Jurevic D, Boni C, Barthelmes D, et al. Torpedo maculopathy
name and initials will not be published and due efforts will
be made to conceal his identity, but anonymity cannot be associated with choroidal neovascularisation. Klin Mon Augen-
guaranteed. heilkd. 2017;234:508 – 14.
13 Parodi MB, Romano F, Montagna M, Albertini GC, PierroL, Arrigo
References A, et al. Choroidal neovascularization in torpedo maculopathy
assessed on optical coherence tomography angiography.
1 Roseman RL, Gass JDM. Solitary hypo-pigmented nevus Ophthalmic Surg Lasers Imaging Retina2018;49:e210–e213.
of the retinal pigment epithelium in the macula. Arch 14 Shirley K, O’Neill M, Gamble R, Ramsey A, McLoone E.Torpedo
Ophthalmol1992;110:1358–1359. maculopathy: disease spectrum and associated (Roseman RL,
1992)choroidal neovascularisation in a paediatric population.
2 Daily MJ. Torpedo maculopath y or paramacular spot syndrome. Eye2018;32:1315–1320
In: New Dimensions in Retina Symposium , Chicago, 1993:11;7
Cite This Article as: Sonia Singh, N.S.Muralidhar, Hemanth
3 Venkatesh R, Jain K, Pereira A, Thirumalesh MB,Yadav NK. Murthy. Torpedo maculopathy with satellite lesion, Delhi J
Torpedo Retinopathy. J Ophthalmic Vis Res 2020;15:187–194 Ophthalmology. 2020; 31 (2) : 90- 92

4 Jain S, Kumawat D, Kumar V. Multimodal imaging of torpedo- Acknowledgments: Nil
shaped fundus lesions: New insights. Indian J Ophthalmol
2018;66:1211-3. Conflict of interest: None declared

5 Williams PJ, Salek S, Prinzi RA, et al Distribution Patterns Source of Funding: None
of Torpedo Maculopathy: Further Evidence of a Congenital
Retinal Nerve Fiber Layer-Driven Etiology. Saudi Journal of Date of Submission: 17 May 2020
Ophthalmology 2019;33:260-267 Date of Acceptance: 19 May 2020

6 Shields CL, Guzman JM, Shapiro MJ, Fogel LE, Shields Address for correspondence
JA.Torpedo maculopathy at the site of the fetal ”bulge”.Arch
Ophthalmol2010;128:499–501. Sonia Singh, MBBS, DO, DNB

7 Chawla R, Pujari A, Rakheja V, Kumar A. Torpedo maculopathy: Retina Institute of Karnataka
A primary choroidal capillary abnormality?. Indian J Ophthalmol 122, 5th Main Rd, Chamrajpet,
2018;66:328-9 Bengaluru, Karnataka, India.
E mail: [email protected]
8 Pian D, Ferrucci S, Anderson SF, Wu C. Paramacular coloboma.
Optom Vis Sci 2003;80:556‑63.

9 Golchet PR, Jampol LM, Mathura JR, et al Torpedo maculopathy.
British Journal of Ophthalmology 2010;94:302-306.

10 Wong EN, Fraser ‑ Bell S, Hunyor AP, Chen FK. Novel Optical
Coherence Tomography Classification of Torpedo Maculopathy.
Clin Exp Ophthalmol 2014;43:342 ‑8

11 Hamm C, Shechtman D, Reynolds S. A deeper look at torpedo

Quick Response Code

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DJO Vol. 31, No. 2, October-December 2020

Case Report

Euphorbia Plant Induced Toxic Keratopathy

Atul Kumar Singh, Ashish Pandey, Anjali Maheshwari

Department of Ophthalmology, Command Hospital (Air Force) Bangalore, India.

Abstract This case report illustrates the severe injury to eye secondary to accidental inoculation of latex content of Euphorbia
plant. An 18 years old was given the task of trimming the hedge in the evening . During trimming, he accidentally
traumatized his right eye with leaf sap. He reported to the emergency department few hours later with profound loss
of vision. On examination, he had a large epithelial defect covering almost three-quarter of the cornea with signs of
keratouveitis. After copious irrigation of his right eye, he was managed conservatively with regular follow up. After
two weeks, his epithelial defect healed and the anterior chamber became quiet. This case highlights the importance of
wearing protective wear during gardening, cutting trees. To the best of our knowledge, this is the youngest patient with
such a large corneal defect almost covering the cornea secondary to euphorbia plant induced latex toxicity

Delhi J Ophthalmol 2020;31;93-94; Doi http://dx.doi.org/10.7869/djo.602



Keywords:Corneal Toxicity, Uphorbia, Keratuveitis, Plant Sap

Introduction Case Report

Euphorbia is a very large and diverse genus of a flowering An 18 years old serving soldier presented to the emergency
plant .Euphorbia umbellata species is a rather succulent, department with severe pain, diminution of vision and
evergreen shrub or a small bushy tree that usually grows up excessive watering from his right Eye of 6 hours duration.
to 5 metres tall, occasionally to 10 metres. It is also known Earlier, during shramdaan in the evening,he was tasked
as the African milk bush. The plant is harvested from the with trimming the hedge surrounding the wall of his unit,
wild for local medicinal use.In India,sometime its leaves when he accidentally got injured by a plant twig
used against snake bites.1. The milky sap causes a severe ( Euphorbia umbellata). He washed his eye immediately
reaction to skin, eye and mouth. on the other side, Euphorbia in running tap water for about a minute post trauma.
species have curative properties also due to the presence of Later in the evening, he reported to this hospital for
various phytochemicals, which constitute the secondary further management. He had also got a sample of the
metabolites of these plants.2,3 We are reporting a case of plant for identification and photos of the bush (Figure 1).
severe keratouveits secondary to milky latex of euborbia On examination, visual acuity in his right eye was hand
umbellate species. The patient managed conservatively with movement close to face not improving with pinhole, left eye
good visual recovery. was 6/6 unaided. Right eye diffuse torch light examination

Figure 1: Plant Leaf of bush Figure 2: Large epithelial defect with gradual healing after treatment

showed mild lid oedema, severe conjunctival chemosis and of herpetic kerato-uveitis presenting as large geographical
circumciliary congestion. Cornea shows central epithelial ulcer was also kept in mind. However, patient history and
defect measuring 8mm X 6 mm involving pupillary region leaf sample pointed out it as a case of plant induced toxic
with full thickness stromal oedema with Descemet’s folds keratopathy. He was diagnosed as a case of kerarouveitis
covering entire cornea (Figure 2) . Anterior chamber showed secondary to plant sap injury. The patient was managed
1+ cells . Pupil was sluggishly reacting to light. Media was with copious irrigation with balanced salt solution (500ml),
hazy and fundus detail could not be visualized. Possibility followed by topical antibiotics ( gatifloxacin 0.3% three

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DJO Vol. 31, No. 2, October-December 2020

times a day), prednisolone acetate (1%) eye drops four 2. Jassbi A.R. Chemistry and biological activity of secondary
metabolites in Euphorbia from Iran. Phytochemistry.
times a day, homatropine 2% twice a day, preservative-free 2006;67:1977–1984.doi: 10.1016/j.phytochem.2006.06.030

tear substitute six times a day. The Patient was observed 3. Ravikanth V., Niranjan Reddy V.L., Prabhakar Rao T., Diwan
P.V., Ramakrishna S., Venkateswarlu Y. Macrocyclic diterpenes
every day on OPD basis. He gradually improved over two from Euphorbia nivulia. Phytochemistry. 2002;59:331–335. doi:
10.1016/S0031-9422(01)00461-7
weeks.the corneal epithelium was gradually healed with no
4. Sofat BK, Sood GC, Chandel RD, Mehrotra SK. Euphorbia
anterior chamber reaction and his vision was regained to 6/9 royaleana latex keratitis. Am J Ophthalmol. 1972;74:634–7

unaided (Figure 2). Discussion 5. Scott IU, Karp CL. Euphorbia sap keratitis: Four cases and
possible pathologic mechanism. Br J Ophthalmol. 1996;80:823–6
The euphorbia is a diverse plant and has 15000 species
6. Eke T, Al-Husainy S, Raynor MK. The spectrum of ocular
with world wide distribution mainly in a hot and humid inflammation caused by Euphorbia plant sap. Arch Ophthalmol.
2000;118:13–6
climate. The ocular reaction varies from mild conjunctivitis
7. Merani R, Sa-Ngiampornpanit T, Kerdraon Y, Billson F, Mc
to permanent bindness.4,5 Though there are few case reports Clellan KA. Euphorbia lactea sap keratouveitis: Case report and
review of the literature. Cornea. 2007;26:749–52
in the literature, ocular changes and the severity of the
8. Amissah -Arthur KN, Groppe M. Beware the ornamental plant.
ocular inflammation may vary with the species of the plant.6. Emerg Med J. 2010 Aug;27(8):647. doi: 10.1136/ emj.2009.089201.
Epub 2010 May 29. PubMed PMID: 20511641.
Symptoms usually start immediately on contact with the
9. Gómez -Valcárcel M, Fuentes -Páez G. Euphorbia grandi - cornis
milky latex. There is burning sensation, pain, photophobia Sap Keratouveitis: A Case Report. Case Rep Oph - thalmol. 2016
Feb 26;7(1):125 -9. doi: 10.1159/000444438.
and lacrimation. After a few hours patient notices a decrease
10. Shields MK, Andrew NH, LaHood BR, Saha N. Eye injuries
in vision along with the above symptoms. A Severe corneal following ocular exposure to euphorbia plant sap: an Australian
and New Zealand case series. Clin Exp Ophthalmol. 2017 Oct
defect can be seen which may not resolve with medical 4. doi: 10.1111/ceo.13081. [Epub ahead of print] PubMed PMID:
28976055
treatment.7,8 The posterior segment is rarely involved.9,10
11. Shlamovitz GZ, Gupta M, Diaz JA. A case of acute
Chemical material in latex in the form of flavonoids, keratoconjunctivitis from exposure to latex of Euphorbia tirucalli
(pencil cactus). J Emerg Med. 2009 Apr; 36(3): 239 -41
alkaloids, phenols, and sesquiterpene lactones can penetrate
12. Joshi D, Shingal P. Ocular Injuries from Plant Sap in Army
the entire cornea and may cause more toxicity in the anterior Soldiers. Med J Armed Forces India. 2008;64(3):293–294.
doi:10.1016/S0377-1237(08)80127-X
chamber. Corneal involvement also depends on the degree
Cite This Article as: Atul Kumar Singh, Ashish Pandey, Anjali
and length of exposure. Treatment after exposure to latex is Maheshwari. A Euphorbia Plant Induced Toxic Keratopathy.
Delhi Journal Of Ophthalmology.2020; Vol 31 (2), Page 93-94
irrigation and topical antibiotics depending on the degree
Acknowledgments: Nil
of damage. Irrigation should continue until pH normalizes.
Conflict of interest: None declared
Cycloplegics may be used if photophobia is present and
Source of Funding: None
topical steroids are used if there is evidence of anterior
Date of Submission: 27 March 2020
chamber inflammation. After primary management, these Date of Acceptance: 29 May 2020

patients should be seen either in OPD or in wards daily to Address for correspondence

ensure that there is no permanent damage to the cornea.11 Wg Cdr (Dr) Atul Kumar Singh

With appropriate supportive therapy and close daily Department Of Ophthalmology
Command Hospital, Old Air Port Road
observation, the condition generally resolves completely Bangalore-India.
Email: [email protected]
within 10-15 days. In the presence of hypopyon , suspected
Quick Response Code
bacterial infection corticosteroids can be started after infection

and epithelial defect improves. Individuals working in

cleaning ,grass cutting should wear protective eye glassess.12

Serious eye injuries can be avoided by simply wearing large

goggle with proper fitting. To the best of our knowledge and

MEDLINE search, this is the youngest patient with large

corneal defect almost covering three quarter of cornea as a

case of euphorbia induced toxic keratopathy.

Conclusion

This case study highlights the relatively unknown potential

toxicity of a common plant. The clinical course may be

affected by particular species of Euphorbia, the amount of

sap exposure, the time between exposure and irrigation,

and other host factors. Daily follow up us required. It is

recommended to ask the patient to bring a sample of the

plant and photos of bushes for better identification. It is

also recommended that individuals working on garden,

lawns,trimming of bushes should wear protective eyeglasses

and to report nearest eye centre if they have direct exposure

to latex of plants. References

1. Jain SK, Srivastava S. Traditional use of some Indian plants by
the islanders of Indian Ocean. Ind J Trad Knowl. 2005;4(4):345–
357

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DJO Vol. 31, No. 2, October-December 2020

Photo Essay

Retained corneal glass foreign body: look for it or miss it!!

Abstract Rinky Agarwal, Rahul Kumar Bafna, Vatika Jain, Namrata Sharma

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

Microbial keratitis (MK) is a potential vision-threatening condition that involves cornea and mandates prompt diagnosis
and treatment to prevent untoward outcomes. Corneal foreign bodies (CFBs) are a common cause of presentation to
ocular emergencies and can be a predisposing risk factor as well as a differential diagnosis of MK. We present a case of
superficial glass CFB that can be mistaken as MK by any novice ophthalmologist.

Delhi J Ophthalmol 2020;31;95-96; Doi http://dx.doi.org/10.7869/djo.603
Keywords: Microbial Keratitis, Corneal Foreign Body, Glass

Microbial keratitis (MK) is a potential vision-threatening nodular degeneration. The age was against diagnosis of
condition that involves cornea and mandates prompt neoplasia and the other two conditions are usually associated
diagnosis and treatment to prevent untoward outcomes.1 with a long-standing presentation and chronic underlying
Corneal foreign bodies (CFBs) are a common cause of disorder ruling them out in the present case. MK was ruled
presentation to ocular emergencies and can be a predisposing out by absence of other signs of infection such as discharge,
risk factor as well as a differential diagnosis of MK.2 epithelial defect, anterior chamber reaction or photophobia.
A 42-year-old-healthy-male presented with ocular irritation The glass CFB, suggested by its characteristic occupational
and localized redness, without an associated photophobia history, was extracted in-toto with the aid of a non-traumatic
or diminution of vision, OD for 2 weeks. On examination, forceps (histopathological examination demonstrated Glass
visual acuity OU was 20/20. Slit-lamp biomicroscopy particle) revealing an underlying vascularized area with
revealed a 3×2 mm well defined elevated corneal lesion in bare stroma that stained positively with fluorescein dye
the inferotemporal part of the right eye with localized limbal (Figure 1b) and showed complete resolution of signs and
vascularization and conjunctival hyperemia (Figure 1a) that symptoms at 4-weeks follow-up on an antibiotic-steroid-
did not take up fluorescein or rose bengal staining and quiet lubricant combination.
anterior chamber and normal posterior segment examination Commonly encountered superficial CFBs include metal
OD. On eliciting detailed occupational history, the patient fragments, stone and wood pieces and rarely glass splinters.
revealed to be an employee in glassware industry for the past In most cases, trauma with glass CFB occurs from explosion
10 years, usually worked without wearing protective eye of glass object, as seen in our case, where high kinetic
wear and reported frequent history of trivial trauma while energy compensates for its low weight. As they are rarely
molding glass. However, he did not remember sustaining encountered, at their first look, these can be mimic MK. As
a similar trauma prior to the onset of present signs and they can sometimes go unrecognised even on sophisticated
symptoms. Various differential diagnosis of superficial CFBs imaging modalities such as computerized tomography,
can be ocular surface neoplasia, corneal keloid and Salzmann eliciting a detailed occupational history is mandatory for

Figures 1: Localized elevated lesion in the inferotemporal part of the cornea with surrounding conjunctival hyperemia (a); intense vascularization seen underlying
the foreign body after its removal (b)

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DJO Vol. 31, No. 2, October-December 2020

their appropriate diagnosis.3 Both MK and CFB are primarily the anterior chamber. British Journal of Ophthalmology. 1969 Jul
clinical diagnoses and advanced corneal imaging with 1;53:453–6.
anterior segment optical coherence tomography may not be 5. Milkowski S. A rare case of spontaneous shifting of intra-ocular
mandatory for their diagnosis and management. glass foreign body 21 years after trauma. Wiad Lek 1978; 31:1065-
Removal of any CFB must be weighed against the hazards 9
of its removal and the necessity for close follow-up. While
neutral sodium silicate (98%) in the transparent glass CFBs Cite This Article as: Rinky Agarwal, Rahul Kumar Bafna,
make them inert and innocuous to the eye, rarely, corneal Vatika Jain, Namrata Sharma. Retained glass corneal foreign
edema, cataract or iridocyclitis can result from its delayed body: look for it or miss it! Delhi J Ophthalmology. 2020;31 (2):95-96
secondary movement.4-5 In our case, it was removed instantly
as the patient was symptomatic due to its presence. Acknowledgments: Nil
The purpose of the present photoassay is to create awareness
about such rare and misleading presentations of glass FBs Conflict of interest: None declared
and to emphasize on detailed history taking, especially
occupational, in establishing a correct diagnosis. This may Source of Funding: None
not only prevent unnecessary mismanagement of the patient
but also lay emphasis on utilization of protective measures Date of Submission: 15 Jan 2020
such as safety goggles in employees working in such Date of Acceptance: 03 May 2020
factories.
Address for correspondence
References Rinky Agarwal, MD, DNB, MNAMS

1. Jeng BH, McLeod SD. Microbial keratitis. Br J Ophthalmol. 2003 Senior resident
Jul;87:805–6.
Dr Rajendra prasad centre for ophthalmic
2. A.R Nalgirkar. Study of Ocular Foreign Bodies in the city sciences, All India Institute of Medical
population. Indian Journal of Occupational and Environmental Sciences, New Delhi India.
Medicine. 2003 May 1;7. E-mail- [email protected]

3. Gor DM, Kirsch CF, Leen J, et al. Radiologic differentiation of
intraocular glass: evaluation of imaging techniques, glass types,
size, and effect of intraocular hemorrhage. AJR Am J Roentgenol.
2001 Nov;177:1199–203.

4. Archer DB, Davies MS, Kanski JJ. Non-metallic foreign bodies in

Quick Response Code

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DJO Vol. 31, No. 2, October-December 2020

Photo Essay

Gluing the Glued Patch: A Glue in Time Saves it all

Rinky Agarwal, Anubha Rathi, Chetan, Namrata Sharma

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

Customized glued sutureless patch grafts can be tried as a definitive treatment for restoring ocular integrity
in smaller corneal perforations. Donor cornea in these grafts is first fashioned to fit the corneal defect by a
lock and key pattern and then secured to the host with the aid of an ophthalmic sealant. Wound dehiscence
Abstract after glued grafts is a serious sight-threatening complication that is rarely reported and warrants urgent
intervention to restore ocular integrity Presently described is a case of wound dehiscence post fibrin-glued
patch graft managed timely by cyanoacrylate glue.

Delhi J Ophthalmol 2020;31;97-98; Doi http://dx.doi.org/10.7869/djo.604


Keywords : Cyanoacrylate Glue, Fibrin Glue, Patch Graft

Photo Essay large perforation and positive Siedel’s test. (Figure-1A-B)
Corneal sensations, fundus examination and microbiological
Customized glued sutureless patch grafts can be tried analysis were all uneventful. After obtaining informed
as a definitive treatment for restoring ocular integrity in consent and starting prophylactic antibiotics-steroid-
smaller corneal perforations.1 Donor cornea in these grafts lubricant combination and treatment for Rheumatoid
is first fashioned to fit the corneal defect by a lock and key arthritis, a customized full thickness corneal patch graft
pattern and then secured to the host with the aid of a sealant. (3.0×1.5 mm oval shaped graft) apposed to the host with fibr
Wound dehiscence post-keratoplasty is a serious sight in-aprotinin tissue adhesive (Tisseel VH, Baxter Healthcare
threatening complication that warrants urgent intervention Corp, Deerfield) was performed under general anesthesia.
to restore ocular integrity.2 Presently described is a case of (Figure-1C) A bandage contact lens (BCL) was placed and
wound dehiscence post fibrin-glued patch graft managed by preoperative medications were continued unchanged. Two
cyanoacrylate glue. weeks later, spontaneous inferonasal wound dehiscence
A 30-year old female suffering from Rheumatoid arthritis with overlying epithelial defect and negative Siedel’s test
presented with diminution of vision right eye. Slit lamp were noted. (Figure -1D) The graft was reposited back
examination revealed an inferotemporal area of sterile gently and a drop of cyanoacrylate glue followed by BCL
corneal melt with prolapsing iris tissue from a 3.0×1.5mm

Figure 1: Figure 1A to 1F represent chronological clinical photographs of the patient; 1A and 1B show inferotemporal peripheral corneal perforation with uveal
tissue prolapse, 1C shows a snugly fit graft and well-formed anterior chamber on post-operative day one, elevated graft margins suggestive of displaced graft
and cyanoacrylate glue with bandage contact lens can be appreciated in 1D and 1E respectively, 1F shows well healed vascularized tissue at 5-months follow up.

E-ISSN: 2454-2784  P-ISSN: 0972-0200 97 Delhi Journal of Ophthalmology

DJO Vol. 31, No. 2, October-December 2020

was applied under topical anesthesia. (Fig-1E) At 5-months 4. Vote BJ, Elder MJ. Cyanoacrylate glue for corneal perforations: a
follow-up, the glue dislodged spontaneously leaving a description of a surgical technique and a review of the literature.
well apposed graft, keratometry values of 45.88D/48.75D at Clin Experiment Ophthalmol. 2000; 28:437–42.
60°/150° and uncorrected visual acuity of 20/40 (compared
to 38.30D/50.20D at 130°/50° and 20/120 respectively at 5. Tan J, Li Y-C, Foster J, et al. The Efficacy of N-Butyl-2
presentation).(Figure -1F) Cyanoacrylate (Histoacryl) for Sealing Corneal Perforation: A
Wound dehiscence after sutureless patch grafts are Clinical Case Series and Review of the Literature. J Clin Exp
rarely reported but can be encountered due to poor and Ophthalmol. 2015; 6:1–6.
unpredictable tensile strength of fibrin glue, as seen presently.
Various modalities such as conjunctival flap, amniotic Cite This Article as: Rinky Agarwal, Anubha Rathi, Chetan,
membrane graft, repeat fibrin glue application or sutured Namrata Sharma Gluing the glued patch: A glue in time saves it
grafts and tectonic keratoplasty can be employed to salvage all!!! Delhi J Ophthalmology. 2020;31 (2):97-98
globe integrity in these cases. However, they carry their Acknowledgments: Nil
own complications such as risk of intense vascularization, Conflict of interest: None declared
transmission of infections, repeat dehiscence, suture-related Source of Funding: None
complications and graft rejection respectively.3 Date of Submission: 4th Feb 2020
Cyanoacrylate glue (CG) is an ophthalmic sealant that Date of Acceptance 14th may 2020
contains esters of cyanoacrylic acid with alkyl side
chains.4-5 While CG has been used previously to manage Address for correspondence
wound dehiscence due to other causes, it’s usage to seal Rinky Agarwal, MD, DNB
a displaced fibrin-glued patch graft is being described for
the first time. It is s cheaper, quicker and easier to prepare Senior resident
than fibrin glue and its inherent antibacterial and anti-
keratolytic activity make it a suitable choice for the present Dr Rajendra prasad centre for ophthalmic
condition.4 Additionally, repeat superficial applications of sciences, All India Institute of Medical
this glue are also possible due to its limited histotoxicity.5 Sciences new Delhi, India.
Nonetheless, various complications like conjunctival and E-mail- [email protected]
corneal irritation, premature dislodgement, vascularization
and masking of underlying microbial keratitis from poor Quick Response Code
visibility associated with its application require close
monitoring till its dislodgement.
From the present clinical picture, it may be emphasized
that CG may make a simple and feasible alternative to other
major procedures in salvaging fibrin-glued corneal patch
grafts.

References

1. Gupta N, Sachdev R, Tandon R. Sutureless patch graft for sterile
corneal melts. Cornea. 2010; 29:921–3.

2. Pahor D. [Characteristics of traumatic versus spontaneous
wound dehiscence after penetrating keratoplasty]. Klin
Monatsbl Augenheilkd. 2013; 230:808–13.

3. Bouazza M, Amine Bensemlali A, Elbelhadji M, et al. [Non-
traumatic corneal perforations: Therapeutic modalities]. J Fr
Ophtalmol. 2015; 38:395–402.

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