DOS_Apr_2008

Contents

S8 ecretary’s Report 2007-2008 Neuro Ophthalmology
O11 utgoing President Address
I12 ncoming President Address 61 Compressive Optic Neuropathy
E5 ditorial
H13 ighlights: Annual DOS Conference Shailesh G.M., Jatin Ashar, Rohit Saxena, Vimla Menon

Cornea

69 Ocular Surface Squamous Neoplasia (OSSN)

Amar Agarwal, Soosan Jacob, Athiya Agarwal

A73 bstracts

F77 orthcoming Events

Cataract Columns

45 Cataract Surgery in Uveitis 83 Membership Form
87 DOS Quiz
Somasheila I. Murthy, Sushma Tejwani
Saurabh Sawhney, Ashima Agarwal
55 Intraocular Lens Power Calculation in Children
T101 earsheet
Jatin Ashar, Manish Kumar Sinha, Bhavin Shah,
Nikhil Bansal, Sreedhara S. Outline Chataracteristics of Corneal Dystrophies
Jaya Gupta, Preeti Paliwal, Radhika Tandon

Attention DOS Member 3

DOS Times is not published in the month
of May & June each year

www.dosonline.org

Delhi Ophthalmological Society Website

www.dosonline.org

We welcome your comments and suggestions on the DOS Web Site. Please mail your
suggestions to [email protected]. The latest DOS Times & Delhi Journal of
Ophthalmology are available online.
To Test Drive the DOS Website, login with your Membership No. & Password
today.

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Secretary’s Report 2007-2008

Honorable President Dr. Lalit Verma, Incoming President Dr. S. Bharti, respected Senior Members of
the society and my dear friends, I welcome you all to this General Body Meeting of the Delhi
Ophthalmological Society for the year 2007.

Delhi Ophthalmological Society is growing exponentially in magnitude each year.

The high points of our society are excellent academics which are highlighted in its clinical monthly Dr. Namrata Sharma
meetings, Midterm & Annual Conferences, publication of monthly bulletin - DOS Times & its journal
- Delhi Journal of Ophthalmology.

The total membership of Delhi Ophthalmological Society is 4587 members with an addition of 299
(Delhi – 35, outside – 264) new members in this financial year (2007-2008).

In the beginning of this year, various subcommittees were constituted which included Ethics & Grievance Committee, DOS Travel
Fellowship Committee, DOS House Committee and Sub committee for formation of guidelines of DOS Monthly clinical meetings.

Ten issues of DOS Times were printed, out of which 7 issues were circulated to 4,500 ophthalmologists and 3 issues were circulated
on a national basis to 11,500 ophthalmologists. The cover page of the DOS Times was changed which was much appreciated. The
quality of the paper as well as printing was improved and now for the first time it is has all colour pages. It had 16 articles by the
international faculty apart from the articles from eminent Indian ophthalmologists. Four issues of DOS Times were accompanied
by Video CD’s for various ophthalmic surgeries. These included “Phacoemulsification surgery for beginners” “Squint surgeries”,
“Diabetic vitrectomies” and “Microincisional cataract surgeries”. These were sponsored by various companies and by the ORBIS
organization. There were a total of 28,000 video CDs which were distributed.

In an endeavor to disseminate educational material, we propose to undertake various practice guidelines. Practice guidelines
series on cataract surgery is currently being modified. It has been examined by a board of eminent ophthalmologists which consist
of 17 members. It was emailed to most DOS members and a revised version will be made as per the suggestions received.

Distribution of DOS Times:

As suggested by the Executive, we have already applied for a Registrar of Newspapers of India (R.N.I.) number which will be
processed in 6 months time, so that DOS Times can be posted from the post office at a nominal cost.

The Website of the Delhi Ophthalmological Society has been completely overhauled, after 4 years. For those of you who have
visited the website you must have realized that it is updated on a daily basis. We started tracking the hits from mid January this year
and in less than 3 months there were 15,220 hits. The features of the website include the following.

1. The members can now update their contact details in real time without sending a written request to the DOS office.

2. For the first time online registration for the conference was made available.

3. Abstracts for free paper & video were submitted online and this year we received an over whelming response. There were 131
abstract submissions for free paper / poster / video presentation.

4. The DOS Times as well as the Delhi Journal of Ophthalmology is available online to the members.

As per the request of the editor and decision taken by the executive, the editor was given a new computer. Regarding the Delhi
Journal of Ophthalmology, the editor will present his report.

10 Clinical monthly meetings were held successfully with stupendous attendance. The attendance was high at all times and there
was an increase of 30% attendance as compared to the previous year. All sessions were interactive and were held on Sunday
followed by lunch. Early bird prizes were given at all the centres.

World Sight Day was celebrated by the Delhi Ophthalmological Society on 11th October, 2007 where 19 centres from the government
and private institutions participated. Free Eye screening camps were held at these centres. The President, Secretary and the
Treasurer visited 4 of these centres along with Andh Maha Vidyala at Punchkuiyan Road. 62 Children were examined and 9
received treatment at Dr. R.P.Centre. At this blind school, eye drops and ointment were given free. The maximum number of
patients seen free of cost were at Dr. R.P. Centre (359) amongst the Government Institutions and Venu Eye Institute (201) amongst
the private centres.

The mid term meeting of Delhi Ophthalmological Society was held on 17th & 18th November, 2007. The highlights of the meeting
include the following:

1. For the 1st time the mid term DOS Meeting was a two day meeting.

2. There were a total of 1,076 registrations which is the highest in any mid term DOS Conference.

3. Wet laboratories were conducted in 7 subspecialties which were attended by over 1000 delegates.

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4. For the first time the live surgery demonstration was held on femtosecond laser surgery and micro phaocemulsification surgery
which was relayed from RP Centre and Centre for Sight to the conference venue.

5. Run for vision was organized on 18th November, 2007.

6. Live surgeries were recorded during the conference for the first time the video CD’s of these were distributed free of cost with
the DOS Times.

7. A cultural evening was held a day before and dinner was also organized.

It was decided by the executive committee that past presidents will get complimentary registration for Mid Term and Annual
Conference of DOS.

DOST’ i.e. Delhi Ophthalmological Teaching programme was launched with the aim of enhancing teaching of the post graduate
(DNB / MD/MS Ophthalmology) students in Delhi and in the national capital region. Under this 3 lectures have already been taken
-”Understanding Squint” by Prof. Pradeep Sharma (attended by 143 students) at Dr. R.P. Centre 2nd was delivered by Prof. Ritu Arora
on “Basic Techniques of Corneal Examination” from Guru Nanak Eye Centre (attended by 113 students) and the 3rd was given by Dr.
Harsh Kumar on “Basics of glaucoma & Medical Management (attended 78 students).

And now on the lighter side of DOS activities : First ever DOS Picnic was organized by Dr. Alkesh Chaudhary and by Dr. Rajendra
Prasad. This was done on the 10th February 2008 at Vedic Gram, Panchgaon, Near Manesar, Gurgaon which was attended by 40
families.

DOS library was shifted from the ground floor of Dr. R.P. Centre to the 4th Floor of Dr. R.P. Centre along with the new office which
was given by the Chief, Dr. R.P. Centre.

DOS Library was attended by over 100 members and 160 video editing were done during the last one year.

DOS Travel Fellowship was granted to Dr. Ajay Aurora for the term January 2007 and to Dr. Tushar Agarwal for the term July 2007
to attend international conferences.

As per the recommendation of Subcommittee of DOS elections we used electronic voting machines this time for the elections. A
total of 4 Electronic Voting Machines were used.

The General body agreed to continue the same auditor at the same renumeration as the previous year (M/s Puneesh Kapoor &
Associates) for the year 2007-2008.

From this year onwards the executive also decided to give life time achievement awards to felicitate the senior ophthalmologist of
the society.

A new and updated directory of the Delhi Ophthalmological Society has been released.

Highlights of the annual DOS Conference

1. The trade area was shifted to front lawns incorporate the Wet Laborites in the area stall. The programme was conducted in 9
halls, 11 international faculty and 398 national faculty from various institutions and private centres attended the meeting.

2. We are grateful to the major sponsors such as Alcon India, Basuch & Lomb, Advanced Medical Optics, Appasamy Associates,
Care Group, Mehra Eyetech , Healthscape, Pfizer, Novartis, Allergan India, KLB Instruments, Zeiss, Biomedix, Raymed, Opto
Global who have contributed. The session in the conventionhalls were recorded and a CD of this will be distributed to the DOS
Members later.

3. “Run for vision” was organized

4. Our Treasurer Dr. Sanjay Chaudhary worked hard in keeping the accounts meticulously. For the first time, we relayed live
surgeries from 3 hospital New Delhi simultaneously with video conferencing. 31 live surgeries of various subspecialties including
squint, refractive and cataract surgery were shown. We have already saved 19 lakhs from the last mid term DOS conference and
I am sure that there will be huge profits from the annual conference too.

5. We also had video stations on which the archive of various videos were shown.

6. There were 24 wet laboratory was and 64 scientific session which were attended by various delegates.

7. There were 121 stalls and 16 major sponsors

8. Awards & Achievements

Obituary

With profound grief we inform the sad demise of Prof. Y. Dayal on 1.1.2008, Prof. L.C. Dutta on 11.1.2008 and Dr. Sitalakshmi.

Dr. Namrata Sharma,

Secretary, DOS

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Outgoing President Address

Incoming President, Dr. Sudhank Bharti,

Secretary Dr. Namrata Sharma, Treasurer Dr. Sanjay Chaudhary

Members of Executive,

Respected Senior members of DOS, My Teachers,

Ladies & Gentlemen !!

Like everything in life has to end, my term as President of this distinguished Society is coming to an end. As
I handover the charge to Dr. Bharti, I would like to highlight achievements of this executive in the year gone
by.

On membership front, we have added 299 members (35 from Delhi & 264 from outside) & total membership Dr. Lalit Verma
of DOS now stands at 4587.

DOS times, the face of our society not only improved in its content, quality, it featured articles from international celebrities. “Video CD”
featuring various ophthalmic surgeries were also distributed along with it. I think, we should thank, Dr. Namrata Sharma for bringing out all the
ten issues of DOS Times in time. We had some problem in distribution of DOS Times after M/s Syntho withdrew its support to DOS. Presently
M/s Raymed is helping us in distribution. Simultaneously the executive decided to apply for a RNI member, which will not only bring down the
cost of distribution but the process will become more streamlined smoother & hopefully with less complaints

The website of DOS dosonline.org has become very vibrant & now you have facility for online submission, online registration, which is already
operational. We have separate sponsor for the maintenance of the website.

Ten monthly meetings were held successfully. Average attendance improved by 30%. At the instance of special committee formed with respect
to monthly meetings & the executive, All monthly meetings had uniform protocol, all were held on Sunday & all had lunch & all were non-
alcoholic.

DOS celebrated “World Sight Day” on 11th October 2009. Nineteen ophthalmic Centres (both Government & Private) helped us in organizing
Free Eye Camps in their respective centres. I along with Secretary & treasures visited Blind School at Panchkuian Road. There blind children were
examined & what was satisfying children could be helped. They were referred to RP Centre.

Mid term Conference was held on 17th & 18th November’2007 in India Habitat Centre, was a great success. There were lot of 1st attached to this
meeting : 2 days event, Wet Labs, Live Surgery, Run for Vision, cultural evening & Dinner.

DOST, a landmark teaching Programme, an initiative towards teaching & imparting skills, was launched by DOS during this year to provide
opportunity to our youngsters to learn from the Masters in respective fields. It also aims to bridge or decrease the gap between the institutes of
Excellence & other institutes where Academics has taken a back seat.

Till Date we have conducted three DOST Programmes. The response has been quite encouraging & overwhelming. It is indeed a delight to see
halls packed with enthusiastic students and the Masters delivering their best. I would also like to thank M/s CIPLA for all their support in smooth
conduction of these programme & also for distribution of Certificates.

1st ever DOS Picnic was organized on 10th February’2008 at Panchgaon near Manesar. Thanks to Dr. Alkesh, Dr. Rajender Prasad. It featured
among other games, parasailing, which was enjoyed by all.

Another 1st has been use of EVM during the election. The annual Conference which has just ended, was a grand success. Lots of 1st again: Live
Surgery from 3 places covering Government & Private hospitals featured 31 surgeries by reputed surgeons. 1st time Squint SICS done. Thanks
to Dr. Pradeep Sharma, Dr. Ruchi Goel & Dr. KPS Malik for helping us. Wet Labs, Booth Lectures were all part of this greatest show.

Run for Vision was also organized during the Annual Conference. Huge, International level Trade show was organized in front lawns of Hotel
Ashok. Teaching Video Stations were put up in convention Hall where in a software was developed and at a touch of screen, the delegate could
watch best of surgeries.

DOS Directory, as you all know, after oxygen & food, communication is the key to survival & for effective communication, we need contact
details & hence the need for directory. I thank Mr. Ruby of Raymed for his help in not only compilation but also sponsoring the total expense
involved in printing the Directory.

Although, we have tried to do our best, I am sure, being human there may have been some lacunae, As is the saying “To err is human. To forgive
Divine”. I beg for forgiveness for for any mistakes which I /my executive may have committed.

In the end I would like to thank the entire executive for their support & cooperation. I owe special thanks to our secretary dr. Namrata Sharma
& our Treasurer Dr. Sanjay Chaudhary without whose support, all what DOS achieved this year would not have been possible. I would also like to
acknowledge the help & advise I received from my seniors. I thank the management of Hotel Ashok, specially Mr. Bhatia for all their help &
cooperation.

Long Live DOS !! Dr. Lalit Verma
Thankyou very much President DOS (2007-2008)

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Incoming President Address

My Dear Dr. Lalit Verma, Dr. Namrata Sharma, Dr. Sanjay Chaudhary, Respected Senior Surgeons and
friends,

It is with utmost humility, I herewith take over the responsibility of the president of Delhi Ophthalmological
Society. Our society has grown over the last decade to become the topmost state ophthalmological society of
the country. We are today the strongest in every sphere be it academic, membership, financial strength or
friendly and cohesive relationship amongst the members. To be a part of this society is an honour in itself of
which I am proud.

Delhi is a cosmopolitan state and has a huge population. From the days of Moghuls Delhi has been a city of Dr. Sudhank Bharti
migrants and has always held the status of star city. Every ruler has made Delhi as their capital and given it
a colour of their own so much so that it is now the rainbow of customs, religions and practices with each colour
mixing and in fact intermingling into the other without any demarcating lines or boundaries. The city-state
has progressed tremendously and has become financial, IT and health services hub besides being the political
power center of the country.

Ophthalmology has changed tremendously over the last two decades and has become one of the most technologically advanced branch of
medicine. This has translated into ophthalmology becoming most machine oriented stream as well as making it a conglomerate of multiple
super-specialities in itself. Barring a few premier institutions , advanced training is not available and currently a postgraduate degree is
practically incomplete unless a fellowship of another 2 – 3 years is done thereafter. DOST is a wonderful step in direction of supplemental
teaching for postgraduates. DOS has number of senior members of national and international repute who can impart practical training worth
more than a fellowship. I wish we should look into the possibility of such programmes under the aegis of DOS.

DOS is already looking into making a guidelines for cataract surgery. A standard consent form for different procedures along with guidelines
for the surgeons will not only make the eye care services more uniform but also take care of majority of consumer litigations. We are fortunate
to have born into a country with the karma philosophy. Most of us as well as our patients have a strong belief in karma theory and any mishap
is blamed on the karma and litigation rate is pretty low. I am sure this is not going to last like that forever and western trends will take over. A
two pronged strategy should be evolved. DOS should have an interactive session with legal experts as well as the insurance companies so as to
keep its members abreast of the consumer issues and how best to address them.

Most of DOS members are so busy in their professional activities that they have little time for recreation. A good trend of DOS picnic was
started last year. This not only recharges your batteries but also improves the feeling of fellowship. Another issue raised by our busy schedule is
our inability to invest our earnings to generate decent returns safely. Today Wealth management has become a specialized field and all banks
like SBI, Yes Bank, HDFC and ICICI are offering these services free. An interactive talk by one of the head of investment banking and sharing
different product will definitely help our members in this sphere.

DOS has number of members with funds to spare. I wish to invite all of them to come forward and put these funds either to institute awards
in specific fields or to start fellowships for the junior members and postgraduate students so that they can present their work in various national
and international meetings.

God has given all of us a wonderful life and knowledge to heal. Last year the world sight day was celebrated as a free eye checkup day by us. I
wish we are able to do this more frequently for the underprivileged specially the students of blind school under the aegis of DOS.

I wish all of you to appreciate the hard work done by my predecessor Dr.Lalit Verma and The Secretary Dr.Namrata Sharma. They have taken
our society to a level which is nearly impossible for other state societies to reach. Due to their untiring efforts, today we have an academic
program where everyone feels honoured to become a faculty in our meetings and our outside members eagerly wait for our twice a year
academic and trade feast. They have created fantastic relations with the trade and have their full support in wet labs, booth lectures and other
activities. We also have top class teachers as foreign faculty.

Last but not the least, the trade members have supported the DOS and are becoming the backbone of our society .I have been in touch with them
to extend financial support to the post graduate students and have received the favourable response.

I take this opportunity to congratulate Dr. Sharad Lakhotia on his winning the elections for the Vice President of our society. I am sure we will
have his ideas and support to make our society achieve greater heights.

I acknowledge that my wife Dr. Raka Bharti, my daughters Dr. Neha and Hina have given me their whole hearted support in all my ventures
sacrificing their time and activities. I have had the support of my associates Dr. Dharitri Samantaray, Dr. Salim Zafar Asaad, Dr. Deven Tuli, Dr.
Manish Kumar besides lots of other friends and well wishers as also the staff members of Bharti Eye Foundation. I am ever indebted to them.

Thank you friends.

Long Live DOS

JAI HIND

Dr. Sudhank Bharti
President, DOS

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Cataract Surgery in Uveitis Cataract

Somasheila I. Murthy1 MS, Sushma Tejwani2 DO

Cataract is a commonly encountered complication of uveitis, Indications for surgery
with an incidence varying from 57-78%. The outcome of
surgery in uveitis was reported as uniformly poor in the past; with Foster et al have described four indications for cataract surgery
post-operative complications like severe inflammation, hypotony
and phthisis bulbi. This is no longer the case. The type of uveitis, • Phaco-antigenic uveitis: active inflammation as a result of
control of inflammation, appropriate surgical technique, intra- leakage of lens proteins, in which case cataract surgery is
ocular lens design and management of post-operative complications mandatory
all play a role in maximizing the outcome.
• Visually significant cataract: with well controlled inflammation
Pre-Operative Assessment and potential for visual improvement exists

Diagnosis and type of uveitis • Cataract impairing visualization of the posterior segment
especially in cases of suspected retinal or disc neovascularization
The type of uveitis determines the final outcome. Fuchs and other retino-choroidal pathology
heterochromic irido-cyclitis (FHI) is associated with excellent
outcome (Figure 1a,b). Uveitis associated with Behcet’s disease,
pars planitis (Figure 2), Herpes simplex and herpes zoster, Vogt-
Koyanagi-Harada (VKH) syndrome and sarcoidosis (Figure 3), may
have a good result provided the inflammation is inactive or has
been controlled for three months prior to surgery.

On the other hand, uveitis associated with juvenile rheumatoid
arthritis and recurrent granulomatous uveitis is often associated
with poorer outcome.

Pre-operative examination

A proper pre-operative assessment includes comprehensive ocular
and systemic history, complete ocular examination and relevant
systemic examination. The anatomical type, and any systemic
association should be carefully established.

In many cases, the posterior segment may not be adequately Figure 1a: Fuch’s heterochromic cyclitis with
visualized. Techniques for assessing visual potential such as potential cataract: preoperative photograph shows diffuse
acuity meter and laser interferometry can be helpful but are limited distribution of keratic precipitates and advanced
in their utility. Fluorescien angiography and Optical Coherence
Tomography (OCT) can detect macular edema and in addition, nuclear cataract
OCT can also detect atrophy, epiretinal membranes and vitreo-
foveal traction. B-scan ultrasonography is an invaluable tool in
assessment of the posterior segment for vitreous opacities, retinal
detachment and choroidal thickening/detachment (thickening would
indicate active disease). Ultrasound biomicroscopy (Figure 4), is
especially useful to detect inflammatory processes situated in the
ciliary body, pars plana, retroiridal and anterior vitreous areas,
including detection of cause of hypotony.

A complete ophthalmic examination should help determine the
cause of visual loss, i.e, whether cataract is the primary cause or the
visual disability is due to other factors. Based on this assessment,
the goal of surgery- visual rehabilitation or improved visualization
of the posterior segment- should be explained to the patient (Figures
5a, b & c).

1. Department of Uveitis and Ocular Immunology, Figure 1b: Post-operative photograph shows a
L.V. Prasad Eye Institute, Hyderabad, India good outcome
2. Narayana Nethralaya, Bangalore
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Figure 2: Posterior subcapsular cataract
in a case of pars planitis

Figure 4: A 43-year-old man complained of
episodes of redness in both eyes since 10 years.
There was no systemic association. Ophthalmic
examination showed light perception vision,
seclusio pupillae and complicated cataract. Intra-
ocular pressure was unrecordably low. Ultrasound
biomicroscopy showed a cyclitic membrane, irido-

lenticular touch and iris bombe

Figure 3: Slit photograph of a patient with biopsy- stepping up the dose of oral steroids to 1mg/kg or
proven sarcoidosis, showing granulomatous keratic immunosuppressive agents such as Azathioprine 1 to 2 mg/kg can
be started at least two weeks or earlier in severe cases. On the
precipitates, anterior chamber exudate and other hand, provided that the uveitis was well controlled three
cataract. Surgical outcome is guarded, in view of months pre-operatively, additional preoperative anti-inflammatory
medications may not be required, as noted in a study published
chronic, recurrent, disease from our institute.

Surgical Techniques

Phacoemulsification (PE) versus extracapsular cataract
extraction (ECCE)

• Cataract impairing visualization of the posterior segment in a Phacoemulsification is the preferred technique due to decreased
patient undergoing vitreo-retinal surgery. iris trauma (prolapse/stretching) and in-the-bag placement of the
IOL, which helps decrease post-operative inflammation.
The primary goal of surgery is of course to improve vision. The
patients must be counseled and explained the likelihood of Various studies have compared phacoemulsification with
improvement of vision based on the presence or absence of factors extracapsular cataract extraction. Although the visual acuities are
that may affect final vision outcome. comparable in the two techniques, the recurrence of inflammation
needing treatment was lower in phacoemulsification (36%)
Pre-operative control of inflammation compared to 51% reported earlier with ECCE. Decreased incidences
of cystoid macular edema and other complications were also noted.
This is the most important step in cataract surgery. A quiescent eye These studies conclude that phacoemulsification with IOL
for at least three months (preferably longer) before surgery has implantation is safe and effective in a majority of patients with
been highlighted repeatedly by several authors. The rule of thumb uveitis.
is to operate only when cells are absent (0 to5) in the anterior
chamber as assessed on slit lamp examination. Peri-operative In our experience, as long as the surgical time and iris manipulations
supplementary inflammatory therapy of oral prednisone 1mg/kg/ are kept to a minimum, the final outcome does not seem to differ
day, along with topical prednisolone acetate 1% eye drops, eight in either technique.
times a day, starting two days before the day of surgery has been
recommended by Foster et al. Management of the small pupil

Other protocols included pre-treatment with dexamethasone Technically, the most challenging step in surgery is management of
(0.01%) four times a day a week before surgery in milder cases, and small pupil. Posterior synechia can be easily separated with an

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(a) (b) (c)

Figure 5a & b: Diffuse and slit photographs of the right eye of a 20-year old female who presented with decreased vision since 4 years.
B-scan revealed retinal detachment in the left eye. The right eye shows seclusio pupillae and membranous cataract. Guarded visual
prognosis was explained. She underwent extra-capsular cataract surgery with sector iridectomy. Post-operatively
Figure 5c: vision did not improve due to disc pallor and healed multifocal choroiditis

iris hook under viscoelastic cushion, and helps in enlarging the
pupil adequately to complete the surgery. Pupillary membranes
are of a fibrotic nature and need to be divided with Vannas scissors
and stripped from the margins using forceps. Mechanical stretching
of the pupil with dilators is best avoided as this would lead to
rupture of iris vessels and increased inflammation post-operatively.
Iris retractors or hooks can be gently applied to hold the pupil.
Multiple (three to four) small sphincterotomies can be made with
Vannas scissors. In cases with ring synechia or extensive anterior
synechia, a peripheral or a sector iridectomy may be required.

Intracapsular extraction

This is now only rarely indicated, in cases with extensive subluxation Figure 6: Slit photograph of traumatic cataract
of the lens, or mobile or dislocated lens following destruction of the with ruptured anterior lens capsule with cortical
zonules in long-standing uveitis. matter in the anterior chamber. Early surgery is

Manual Small Incision cataract surgery indicated to prevent phaco-antigenic uveitis

In this technique, the nucleus is removed through a sclero-corneal
tunnel incision, and has the advantage of sutureless surgery.

Pars plana lensectomy and vitrectomy

The most common setting for lensectomy with vitrectomy is in vitreous is associated with reactivation of secondary immune
juvenile rheumatoid arthritis-associated uveitis. This has been response, the therapeutic benefit of pars plana vitrectomy has not
advocated as a means of preventing cyclitic membrane formation, been clearly established in chronic uveitis, and therefore it is not
by total elimination of the scaffolding upon which such membranes recommended routinely in these patients. This is because there are
could form. Lensectomy-vitrectomy followed by soft contact lens definite complications associated with this combined procedure,
correction for aphakia in children with uveitis has been reported as including increased incidence of CME, increased post-operative
a safe technique with good functional results. inflammation, choroidal hemorrhage, vitreous hemorrhage, retinal
detachment, late IOL decentration/dislocation. Therefore, our
Pars Plana Vitrectomy current approach is to extract the cataract first, assess the impact of
the vitreous opacification post-operatively and plan vitrectomy for
The presence of significant vitreous opacities may indicate the need a small minority of cases.
for simultaneous vitrectomy with cataract surgery. The cataract can
be removed either by phacoemulsification or ECCE and a near Intraocular Lens Implantation in Uveitis
total pars plana vitrectomy is performed. The cataract is extracted
using a sclero-corneal or clear corneal incision. A larger (6mm) Previously, IOL implantation was contraindicated in uveitic cataracts
capsulorhexis is planned. The lens is removed by because of high rates of complications like formation of pupillary
phacoemusification. The pars plana vitrectomy is then completed and cyclitic membranes and IOL decentration and capture. Several
and two ports are sutured. A foldable acrylic lens is implanted studies have now shown that with adequate control of
through the cataract incision. Intraviteal steroid can also be injected inflammation, a PCIOL can be safely implanted in uveitis. Several
at the end of surgery (dexamethosone or triamcinolone). authors have published similar results and most recognize in-the-
bag placement as a key factor in preventing IOL related
Although experimental studies have shown that persistence of complications.

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Immediate post-op: severe post-op inflammation

Severe post-op inflammation may occur (Figure 8a and b). Topical
steroids every hour and cylcoplegics like atropine, along with
stepping up of oral steroids is often required. Recombinant tissue
plasminogen activator injection into the anterior chamber has also
been reported to disperse the fibrinous reaction.

Cystoid macular edema

CME is a major cause of reduced post-operative visual acuity. The
incidence ranges from 18 to 56 %. The management includes injection
of peri-ocular corticosteroid (40mg Triamcinolone acetonide in the
sub-tenon space). In refractory CME, oral prednisolone and other
immunosuppressive agents (as steroid-sparing) are required.

Figure 7: Hyphema noted on the first post- Intravitreal injection of Triamcinolone (4mg in 0.1 ml) is also a
operative day in an uneventful treatment modality however complications like secondary ocular
hypertension has been reported to occur in about 40% cases
phacoemulsification in healed anterior uveitis following this injection; and endopthalmitis which was reported in
1in1000 patients.

Indications and contraindications Secondary glaucoma
A transient rise of post-operative IOP is common after surgery.
A PCIOL can be safely implanted in cases of idiopathic non- Beta-blockers and carbonic anhydrase inhibitors can be used while
granulomatous anterior uveitis, HLA-B27 associated uveitis and miotics and prostaglandin analogues should be avoided.
Fuchs heterochromic iridocyclitis. Moderate success was noted in
VKH, sympathetic ophthalmia, Behcet’s disease, pars planitis and Table 1: Indications for PCIOL Implantation in Uveitis1
any burnt out or inactive uveitis (Table 1).

Most consider IOL implantation contraindicated in children with Good to excellent outcome anticipated
JRA-associated uveitis, since the IOL is presumed to act as a scaffold • Fuch’s heterochromic iridocyclitis
for the formation of intra-ocular membranes further leading to • Burnt-out or inactive idiopathic anterior uveitis of HLA-
cyclitic membranes, hypotony and eventual phthisis bulbi.
B27 associated uveitis
IOL designs and biocompatibility • Inactive toxoplasmosis

The design and material of the intra-ocular lens also can influence Moderate to good outcome anticipated
the outcome of surgery. In a prospective randomized trial, Alio et al • Pars planitis
studied the comparative performance of various IOL materials • Behcet’s disease
which included hydrophobic acrylic, silicon, PMMA and HSM- • Intermediate uveitis
PMMA. Their results suggest that acrylic IOLs provided a better • Sympathetic ophthalmitis
visual outcome and lower rate of complications. Amongst the • Birdshot retinochoroidopathy
current generation of IOLs, foldable acrylic IOLs (and not silicon) • Vogt Koyanagi Harada syndrome
have been shown to have a better biocompatibility and are the • Sarcoidosis Inactive infections such as tuberculosis, syphilis
preferred lens for uveitic cataracts.
and borreliosis
Complications and Management
Poor outcome anticipated (IOL contraindicated)
Commonly encountered intraoperative complications of cataract • Juvenile rheumatoid arthritis
surgery (posterior capsular tear etc) may occur during this surgery. • Uveitis in less than 12 years of age
Additionally, zonular dehiscence may be more frequent due to • Hypotony associated with uveitis
weakening of zonules from long standing inflammation46. • Chronic granulomatous recurrent uveitis
• Advanced disease (VKH, Sympathetic ophthalmia,
Hyphema
Behcet’s)
Amsler’s sign (bleeding from filiform iris vessels) can be seen in
FHI. Trauma to iris vessels during synechiotomy can lead to DOS Times - Vol. 13, No.10, April 2008
hyphema. (Figure 7) Intra-operative air tamponade or intracameral
adrenaline can be used. Post-operative hyphema can either be lysed
with tissue plasminogen activator (10 microgram in 0.1 ml of buffered
saline) or intense anti-inflammatory therapy alone may suffice. In
case of a large clot in the anterior chamber, surgical removal is
advisable.

48

(a) (b)

Figure 8a & b: Slit photographs showing increased anterior chamber reaction one-week
post-operatively in patient with Vogt-Koyanagi-Harada disease.

The other causes for increased IOP include exacerbation of pre- (Figure 8, 9). These require multiple Nd:YAG laser sessions and
existing glaucoma, secondary angle closure glaucoma due to higher laser energy. These membranes tend to recur and surgical
posterior synechia and pupillary block due to inflammatory removal is advocated, with concomitant use of topical or depot
membranes or IOL capture. A planned peripheral iridectomy intra- steroids.
operatively or use of the Nd:YAG laser post-operatively would
help; however the fibrinous reaction can often occlude the laser Overall, in most cases, PCO can be managed by performing an
iridotomy. In cases of glaucoma not controlled medically or by Nd:YAG laser capsulotomy after the inflammation has subsided.
laser, filtering surgery, usually trabeculectomy with anti-metabolite Increased topical steroids are required post-procedure, slowly
or valve implant should be performed earlier rather than later, to tapering over four to six weeks.
prevent glaucomatous optic atrophy.
Hypotony
Uveitis flare-up
Fortunately, not often seen in well controlled uveitis, post-operative
Recurrent episodes of the primary disease may continue to occur hypotony is a grave complication. This may be temporary, as a
after cataract surgery. This could be triggered either by the result of ciliary body shutdown secondary to inflammation, in which
inflammatory stimuli related to the surgery or as a part of the case there may be a response to intensive anti-inflammatory
natural course of the disease. Prompt institution of corticosteroids treatment. Tractional ciliary body detachment may also cause
in full immunosuppressive doses (1mg/kg body weight or more) is hypotony, for which surgical excision of the membranes and IOL
indicated. Reactivation of pars planitis, sympathetic ophthalmia, explantation8 combined with pars plana vitrectomy and silicon oil
VKH, Behcet’s, JRA and sarcoidosis are commonly known to occur. insertion may be necessary. UBM is a useful tool to detect ciliary
body detachment.

Persistent inflammation

In contrast to recurrence of the primary disease, persistent
inflammation refers to those cases where low-grade inflammation
persists months after cataract surgery. This could be related to the
surgical technique (excessive surgical manipulation), IOL design
(three piece lenses with polypropylene haptics) or IOL position
(sulcus fixated, anterior chamber fixated lenses) or inadequate
treatment or due to low-grade infection. Mechanical irritation of
the iris in ciliary sulcus-fixated lenses may provide a chronic
inflammatory stimulus with cytokine release and inflammatory cell
migration at the site of inflammation. In these cases, IOL
explantation may be indicated.

Posterior capsular opacification (PCO)

PCO is a common occurrence. Inspite of meticulous surgical Figure 9: Optic capture and dense pupillary
technique and careful cortical clean-up and capsule polishing and membrane in a patient with chronic posterior
the use of new generation IOLs with increased biocompatibility,
PCO is noted in 30 to 50% of the patients, majority requiring uveitis after cataract surgery
Nd:YAG laser capsulotomy. Recurrent and chronic uveitis can also
cause fibrous membranes and dense fibrosis in certain cases 49

www.dosonline.org

Summary 3. Foster CS, Vitale AT. Cataract surgery in uveitis. Ophthalmol Clin
North Am 1993;6:139-146.
It is possible, in fact even expected to achieve successful visual
outcomes following cataract surgery in uveitis. The predictability 4. Holland GN. Intraocular lens implantation in patients with juvenile
has improved primarily because of a higher level of understanding rheumatoid arthritis-associated uveitis: an unresolved management
of the uveitic disease among the clinicians. Pre-operative factors issue. Am J Ophthalmol 1996;122:161-170.
include proper patient selection and counseling and pre-operative
control of inflammation. It is now well recognized that chronic 5. Ciardella AP, Prall FR, Borodoker N, Cunningham ET Jr. Imaging
inflammation, even low grade, can irreversibly damage the retina techniques for posterior uveitis. Curr Opin Ophthalmol.
and optic nerve and therefore inflammatory control both pre and 2004;15(6):519-30.
post-operatively is vital. The use of immunosuppressive agents
other than steroids also helps control inflammation and has enabled 6. Hazari A, Sangwan VS. Cataract surgery in uveitis. Indian J of
long-term use of these agents especially as steroids sparing Ophthalmol, 2002
medication. Management of post-operative complications especially
inflammation and glaucoma earlier rather than later has also 7. Foster RE, Lowder CY, Meisler DM, et al. Extracapsular cataract
contributed to improved outcomes. Still several questions are left extraction and posterior chamber intraocular lens implantation in
unanswered, especially in the area of pediatric uveitis with cataract, patients with uveitis. Ophthalmology 1992;99:1234-1240
which continues to challenge the ophthalmologist to further refine
the surgical technique and search for new treatment modalities. 8. Suresh PS, Jones NP. Phacoemusification with intraocular lens
implantation in uveitis. Eye 2001;15:621-628.
References
9. Rahman I, Jones NP. Long-term results of cataract extraction with
1. Velilla S, Dios D, Herraras Jm et al. Fuchs’ heterechromic iridocyclitis; intraocular lens implantation in patients with uveitis. Eye
a review of 26 cases. Ocualr Immunol Inflamm 2001;9:169-175 2005;19:191-197.

2. Foster CS, Rashid S. Management of coincident cataract and uveitis. 10. Flynn HJ, Davis JL, Culbertson WW. Pars plana lensectomy and
Current Opinion in Ophthalmology 2003;14:1-6 vitrectomy for complicated cataracts in and juvenile rheumatoid
arthritis. Ophthalmology 1988;95:1114-1119.

11. Abela-Formanek C, Amon M, Schild G, Schauersberger J, et al.
Inflammation after implantation of hydrophilic acrylic, hydrophobic
acrylic, or silicone intraocular lenses in eyes with cataract and uveitis:
comparison to a control group. J Cataract Refract Surg.
2002;28(7):1153-9.

First Author
Somasheila I. Murthy MS

50 DOS Times - Vol. 13, No.10, April 2008

Intraocular Lens Power Calculation in Children Cataract

Jatin Ashar MBBS, Manish Kumar Sinha MBBS, Bhavin Shah MBBS, Nikhil Bansal MBBS, Sreedhara S. MBBS

Intraocular lens implantation at the time of the cataract surgery Refractive goal after cataract surgery
as a primary procedure has become a routine in most of the
childhood cataract surgery. Having had an idea about the expected postoperative myopic shift,
one can decide on the postoperative refractive goal to be achieved
However, its still a matter of debate what should be the power of in these children.
the intraocular lens to be used.
Enyedi et al recommended a postoperative refractive goal of +6 for
During initial days of use of intraocular lens for cataract surgery in a 1-year-old, +5 for a 2-year-old, +4 for a 3-year-old, +3 for a 4-
children an adult power of intraocular lens was used. This lead to year-old, +2 for a 5-year-old, +1 for a 6-year-old, plano for a 7-
hyperopia. Uncorrected hyperopia in children caused or aggravated year-old and —1 to —2 for an 8-year-old and older
the amblyopia.
For older children, it is recommended that lens power be calculated
In order to minimize this amblyogenic effect, emmetropization of for emmetropia, and then adjustments be made to avoid greater
the intraocular lens power was preferred by some. This gave an than 3.00 D of postoperative anisometropia
advantage of spectacle or contact lens free correction for initial
days, however, the child develops myopia over the passage of years. In infants however there was a wide range of variation as regards
the opinion for the refractive goal. For infants at 6 months of age,
Hence a tailor made approach is sought to while deciding the ranging from emmetropia to high hyperopia (defined as less than 7
intraocular lens power in children. D), with most aiming for moderate hyperopia (defined as more
than 3 D but less than 7 D). For infants at 12 months of age, most
While deciding the intraocular lens power in children it is important respondents aimed for moderate or mild (defined as > 0 D but < 3
to address to the following problems: D) hyperopia.

1. How much of myopic shift to be anticipated at a particular age Dahan suggested that the final aim of the refraction should be an
undercorrection of 20% in infants and 10% in toddlers. Depending
2. What should be the target refraction during initial days after on the axial length it is recommended that following IOL power
placement of the intraocular lens. must be used:

The maximum axial growth of the eye ball occurs during the first Axial length IOL Power
two years of life. The change in the keratometric power of the eye
is complete by the age of six months, after which it more or less 17mm 28D
stabilizes. The lens power decreases by more than 10 D during the
first year of life, then drops only 3 to 4 D from 2 till 10 years after 18mm 27D
which it stabilizes. The axial growth of the eye after cataract surgery
can be a part of the normal growth of the eyeball or may be 19mm 26D
influenced by factors such as age at surgery, visual input, the
presence or absence of an IOL, laterality, genetic factors and 20mm 24D
interocular axial length difference.
21mm 22D

Age less than 2 years at the time of surgery gives a significant greater Plager recommended that the refractive aim should be +5D in a 3
predicted myopic shift and greater variance in the predicted year old, +4 D in a 4 year old, +3 D in a 5 year old, +2.25 D in a 6
refractive change than those older than 2 years at the time of surgery. year old, +1.50 D in a 7 year old child, +1 D in a 8 year old child, +
The ideal IOL power should not cause high myopia in adulthood. 0.5D at 10 years of age.
Hence, it is important to customize the IOL power by anticipating
the expected myopic shift and under-correction of eye where IOL According to Crouch the refractive goal should be +4 D for less
has been put. than 2 years, + 2 to 3 D for 2 to 4 years of age, + 1D to +2 D for 4 to
6 years of age, upto + 1 D for 6 to 8 years.
Expected myopic shift after cataract surgery
According to Abdrea and Raina a 10 % standard reduction in the
There have been a number of studies to quantify the amount of IOL power calculated by SRK formula should be used in patients
myopic shift after cataract surgery. All of these studies gave variable between 2 to 8 years of age.
results.
Prost suggested an under correction by 20% in children operated in
years 1 and 2, 15% in those operated in age 2 and 4, 10% in those
operated between 4 and 8 years and emmmetropia at 8 years.

Dr. Rajendra Prasad Centre for Ophthalmic Sciences, Calculation of intraocular lens power
All India Institute of Medical Sciences, New Delhi-110029
Having made the decision of the cataract surgery with IOL
implantation and the postoperative desired refractive goal one must

www.dosonline.org 55

Table 1: Studies on myopic shift following cataract surgery

Author Follow up duration Results
McClatchey and Parks
Vanathi et al 11 years 6.6-diopter mean myopic shift (range —36.3 to 2.9)
Crouch
Mean of 7.8 years. mean myopic shift of 7.35 D

Mean follow-up by age group a mean myopic shift of 5.96 D in children operated on
ranged between4.38 and at 1 to 2 years of age, 3.66 D in children operated on
6.35 years at 3—4 years of age, 2.03 D in children operated on at
7—8 years of age, 1.88 D on children operated on at
Plager 9—10 years of age, 0.97 Don children operated on at
11—14 years of age, and 0.38 D on children operated
on at 15—18 years of age

Mean myopic shift of 4.60 D in children operated on
at age 2—3 years, a mean myopic shift of 2.68 D on
children operated on at age 6—7 years, a mean myopic
shift of 1.25 D on children operated on at age 8—9
years, and a mean myopic shift of 0.61 D on children
operated on at age 10—15 years.

go ahead with the calculation of the intraocular lens power. However, It works best for an axial length range of 22.5 to 25 mm
it has been an issue of controversy for years about the formula to
be used for IOL power calculation. The formula generally under corrects short eyes and overcorrects
eyes with long ALs, because it attempts a linear fit to a hyperbolic
There are a few important components for IOL power calculation. relationship.

These include : The first generation formula assumed that the anterior chamber
depth was constant, which is in fact the reason for the formula
1. Axial length being less accurate in long and short eyes.

2. Keratometry For this reason second generation formulae were derived where in
AC depth was considered as an additional parameter while
3. Clinical parameters such as age, needs and desires, visual acuity, calculating the IOL power. With this emerged the Holladay formula
compliance with contact lens and glasses, status of fellow eye, for IOL power calculation.
family history of high refractive error.
Hoffer developed the third generation formula where deepening
Calculation of axial length and keratometry of the ACD with increasing AL and with increasing corneal curvature
was considered.
A scan ultrasound and keratometry measurements on children is
very difficult as the child may not cooperate for the examination. Further, the SRK/T formula was developed which is a nonlinear
These calculations can be done under anaesthesia. A scan theoretical optics formula empirically optimized for postoperative
ultrasound using immersion or contact method is used to calculate anterior chamber depth based on axial length, retinal thickness
the axial length of the eye. correction for AL, and corneal refractive index.

Errors in axial length are most significant errors in IOL power The Holladay formula is considered to be most accurate for eyes
calculations. with an axial length between 22 and 26 mm. The Hoffer Q formula
is considered to be most accurate for short eyes (<24.5mm). The
It can account to 2.5D/mm in IOL power. SRK/T formula is considered optimal for long eyes (>26mm).

Keratometry measurement is done using an auto keratometer (hand Table 2: IOL Power calculation formulae
held) while the child is under anaesthesia. While performing the
keratometry it should be kept in mind that the cornea is not dry. In The SRK Formulas
cases of irregular corneas such as cases with corneal lacerations,
keratometry of the other eye can be used. 1. IOL Calculation Using the SRK Formula

The power calculation formulae fall into two categories: D1=A1 — 0.9 Km — 2.5 Am

1. Regression formula Al IOL constant in diopters

2. Theoretical formula D1 Primary implant power predicted by the SRK II formula

Sanders-Retzlaff-Kraff (SRK) formula, are based on mathematical Am Axial length in millimeters
analysis of a large sampling of postoperative results in adults.

56 DOS Times - Vol. 13, No.10, April 2008

Km Average K reading surgeon and IOL.

2. IOL Calculation Using the SRK II Formula C. The Holladay Formula

D1 = A1 — 0.9 Km — 2.5 Am - Rsγ 1. IOL Calculation Using the Holladay Formula

Al IOL constant in diopters D3=1336

D1 Primary implant power predicted by the SRK II formula βr— acor — 0.001 Rs
Am Axial length in millimeters [v(βr — acor) + α acor r]
Rs Desired postoperative refraction in diopters
Km Average K reading (acor—d—SF) {βr—d—SF—0.001 Rs
Where [v(βr—d—SF) + α(d+SF) r]}
Al = A + 3 for Am < 20.0 mm
Al = A + 2 for 20.0 < Am < 21.0 D3 Primary implant power predicted by the Holladay equation
Al = A + 1 for 21.0 < Am < 22.0 acor Corrected axial length in millimeters
Al = A for 22.0 < Am < 24.5 v Vertex distance in millimeters
Al = A — 0.5 for Am > 24.5 SF Holladay’s surgeon factor in millimeters
and Where
γ = 1.00 for Al — 0.9 Km — 2.5 Am < 14.00 mm r = 337.5 / Km
γ = 1.25 for Al — 0.9 Km — 2.5 Am > 14.00 mm β = nv / (nc — 1) with nv = 1.336 and nc = 1.333333
B. IOL Calculation Using the Hoffer Q Formula α = 1.0 / (nc — 1)
D2={1336 / (Am—d—0.05)} Rag = r for r > 7 mm
Rag = 7 mm for r < 7 mm
—{1.336/1[1.336/(Km+Rs)] With
—[(d+0.05)/1000]} AG = 0.533 Am for AG < 13.5 mm
D2 Primary implant power predicted by the Hoffer equation AG = 13.5 mm for AG > 13.5 mm
d Chamber depth (ACD) in millimeters d = ACD = 0.56 + Rag — √ (Rag2—AG2/4)
Where acor = Am + Tr where Tr = 0.200
with SF = xxx X Aconst + yyy mm

ACD = pACD+0.3(Am—23.5) Summary

+ (Tan Km)2+(0.1M (23.5—Am)2 Intraocular lens power calculation in pediatric cataract surgery still
remains a matter of debate. The final refractive goal, age, laterality,
x Tan [0.1(G—Am)2]—0.99166 amblyopia status, compliance to glasses, family history of myopia,
expected degree of myopic shift all contribute to the final IOL power
If Am < 23, M = +1 G = 28 decision in children. In spite of all the efforts, its not uncommon to
have refractive surprises after cataract surgery in children. The
Am > 23, M = –1 G = 23.5 most appropriate formula for pediatric eyes still remains an open
question to be answered.
The personalized ACD (pACD) is set equal to the manufacturer’s
ACD-constant, if the calculation was selected to be based on the References
ACD-constant. In case the A-constant was chosen, pACD is derived
from the A-constant according to (from Holladay et al) 1. Foster A, Gilbert CE, Rahi JS. Epidemiology of cataract in childhood.
J Cataract Refract Surg. 1997;23:601-604.
pACD = ACD—const=0.58357
2. Dandona L, Williams JD, Williams BC, Rao GN. Population-based
x A-const—63.896 assessment of childhood blindness in southern India. Arch Ophthalmol
1998;116:545-6.
Personalization of the pACD is the process whereby one enters the
IOL power actually used and the resultant spherical equivalent 3. Rahi JS, Sripathi S, Gilbert CE, Foster A. Childhood blindness in
refractive result and back-calculate what ACD would have produced India: causes in 1318 blind school students in nine states. Eye 1995;
an error of zero. If one calculates this “perfect ACD” for a whole 9:545-50.
series of eyes (using same surgeon and IOL style), average the
number and that becomes the personalized factor for that

www.dosonline.org 57

4. Duane’s clinical ophthalmology 2005. Foundation volume 1, chapter 7. Crouch ER, Crouch ER, Jr. , Pressman SH. Prospective analysis of

15-lens. pediatric pseudophakia: myopic shift and post operative outcomes.

5. Mc Clatchey SK, Hofmeister EM. Intraocular lens power calculation Journal of Aapos.2002;6(5)277-82.

for children. Pediatric Cataract Surgery. Chapter 7; 2005;30-8 8. Plager DA, Kipfer H, Sprunger DT. Refractive changes in pediatric

6. Dahan E, Deyseday MU. Choice of lens and dioptric power in pediatric pseudophakia. 6 year follow up. Journal of Cataract and Refractive
pseudophakia. Journal of Cataract and Refractive Surgery 1997; 23( Surgery. 2002; 28(5):810-15.

Suppl 1):618-23.

First Author
Jatin Ashar MBBS

Congratulations

Dr. Hari Mohan (Padam Bhusan), Director Mohan Eye Institute,
New Delhi has been conferred Doctor of Sciences (Honoris Causa)
of Sanjay Gandhi Postgraduate Institute of Medical Sciences,
Lucknow for having distinguished himself for eminent services in
the field of medical science with relevance to humanity on 14th
January, 2008 by H.E. Shri T.V. Rajeshwar, Governor of U.P.

58 DOS Times - Vol. 13, No.10, April 2008