DOS_sept_2010

Contents

E5 ditorial Paediatric Ophthalmology

Focus 53 Paediatric Eye and Vision Screening

15 Wet Age-related Macular Degeneration Neha Goel, Gauri Bhushan, Usha Kaul Raina, Meenakshi Thakar,
Basudeb Ghosh
Cataract
Miscellaneous
25 Precautions for Cataract Extraction in HIV Positive Cases
59 Group Practice in Ophthalmology
Kamaljeet Singh, Varun Kharband
Vidushi Sharma, Suresh K Pandey
31 Key Challenges in Restoring Sight to Children with Cataract
F67 orthcoming Events
Subodh Kumar Sinha, Rajesh Noah, Gaurav Kakkar

SQuint Columns

37 Re-operations for Horizontal Muscles in Strabismus 71 Membership Form

Virender Sachdeva, Ramesh Kekunnaya, Amit Gupta, Vaibhev Mittal,
B. Venkateshwar Rao

Cornea Tear sheet

47 Superior Limbic Keratoconjunctivitis (SLK) 79 Allergic Conjunctivitis

Ramendra Bakshi, Mahipal Sachdev Jasmita Popli

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4 DOS Times - Vol. 16, No. 3, September 2010

Editorial

My Dear Friends and Colleagues,

Dear Friends

I hope you have liked this new look of the DOS times. We continuously strive to make it more attractive,
more readable and more relevant. Your views and your contributions are always welcome. I am just a
phonecall or an email away from you, so send them on.

The common wealth games are on and inspite of the hurdles and hiccups, there is a festive atmosphere
in Delhi.We wish to continue this fest with our own extremely popular Midterm Conference on 27th
and 28th November at India Habitat Centre.

The theme is “Ophthalmology Techniques and Innovations”. The conference website is functional at this address http://www.
dosonline.org/midterm2010/index.html. It is possible and preferable to get yourself registered online to prevent any last minute
hassles.

Our website www.dosonline.org has been updated and wears a new look too.

One of the innovations in the midterm will be the “E Poster” lounge. Here instead of the conventional hard copy posters, there
will be an E Poster competition and the theme this time is “Public Awareness and Education on eye problems”.

The DOS emphasis on continuing education and training of residents and young ophthalmologists continues. The Skill
Transfer{ST} programme has already kicked off with “Squint” and the next one is on Oculoplastics on 19th November. This
will be followed up by ST workshops on Uvea, Contact Lenses, Cornea, Glaucoma, Retina, and of course-you guessed it!
Refractive Surgery.

The Delhi Ophthalmological society is taking a new initiative.

We are interacting with other health care providers like Delhi Medical Association for diabetic retinopathy awareness camps
etc. This should also make a platform for inter organizational and society networking and support. I think this is the call of
the times.

See you friends, at the midterm. Please get your self registered as soon as possible and keep the conference dates free from
any interference.
Yours Truly.

Thanking you,

Dr Amit Khosla
Secretary,
Delhi Ophthalmological Society

Editor-in-chief

Amit Khosla MD, DNB

Advisor DOS Correspondents DOS Office

H.K. Tewari MD, FAMS, DNB Rajpal MD Nidhi Tanwar MD Room No. 2225, 2nd Floor,
Ashok K. Grover MS FRCS S.P. Garg MD, MNAMS Gagan Bhatia DOMS New Building, Sir Ganga Ram Hospital,
J.K.S. Parihar MS, DNB A.K. Singh MS Vipul Nayar DOMS, DNB, MNAMS Rajender Nagar, New Delhi - 110 060
Shashi N. Jha MD J.L. Goyal MD, DNB Daraius Shroff MS Tel.: 91-11-65705229
Sudershan Khokhar MD Ritika Sachdev MS

Email: [email protected]

Editorial Board Rajiv Sudan MD Deependra Vikram Singh MD Website: www.dosonline.org
Neera Agarwal MS Sanjiv Mohan MS
Ruchi Goel MS, DNB, FICS Poonam Jain MS Ajay Kumar Agarwal MS, DNB Cover Design by: Amit Chauhan
Sanjeev Gupta MD, DNB Neeraj Verma MS Anuj Mehta MS Published by: Dr. Amit Khosla for Delhi Ophthalmological Society
Sanjay Khanna MS Vivek Gupta MD, DNB Naginder Vashisht MD
Y.C. Gupta MS Amit Gupta MD Deven Tuli MS Printers: Symmetrix
Sarita Beri MD S.K. Mishra MS Prakash Agarwal MD E-mail: [email protected]
Devindra Sood MS J.S. Guha MS V. Rajshekhar MS
Umang Mathur MS Manisha Agarwal MS Jasmita Popli MS
Rajesh Sinha MD, DNB Hardeep Singh MD Himanshu R. Gupta MS
Rohit Saxena MD Kapil Midha MD
Hemlata Gupta MS, DNB

www.dosonline.org 5

Presidential Address

All is well and we are not idiots

Dear friends & Colleagues,

A Society of more than five thousand five hundred members –

well it is a very large family. Large families are always difficult to

handle because of the possibility of variation of thinking pro-

cess. I believe most of the eye surgeons think alike and have

common objectives and the inner self operates in a strong and

positive manner to maintain high moral standards. But aberra-

tions can take place with degradation of moral values leading to

moral corruption. Strange enough these aberrations also get

absorbed into the society with a temporary depressive phase. Dr. P.V. Chadha

And so the DOS has recovered and I genuinely feel all is well.

Patience, tolerance and time are the best instruments to win over such situations.

Our Society is taking some forward steps. The Delhi Journal of Ophthalmology has been
indexed with the Index Copernicus. The editor and his full team of advisors need to
credited for the same for achieving this target.

The two conferences in store for you are – the Mid-term Conference being held on 27-
28th November, 2010 at India Habitat Centre and the Annual Conference on 15-17th April,

2011 at Hotel Ashok. These conferences are going to bigger in scale, better in academic

content and best in organization.

I hope you are observing the advertisements on the website and the DOS Times.

The DOS teaching programme for our younger colleagues is coming up soon in the
month of January 2011. We have augmented the affair with a live surgery workshop. The
Venue remains the R&R Hospital Delhi. Our motto is more of subject matter and more
interaction between the teacher and the taught.

Registration is already started; may seats have filled. Since limited seats are there,
please be quick to pick up your seat.

Well friends, enjoy your profession and achieve the gift of satisfaction. That is Gods best
blessing.

With best wishes you, one and all.

Your truly,

Dr. P.V. Chadha,
President, DOS

www.dosonline.org 7

Plea se join us in New Delhi

TRENDS IN

Conference Secretariat :

Dr. Amit Khosla, Secretary

Delhi Ophthalmological Society

Room No. 2225, 2nd Floor
Sir Ganga Ram Hospital
Rajinder Nagar, New Delhi - 110029, India
Email : [email protected]
Website : www.dosonline.org

8 DOS Times - Vol. 16, No. 3, September 2010

TRENDS IN ANNUAL CONFERENCE OF

INDIA Delhi
Ophthalmological
Society

15th to 17th April, 2011,
Friday, Saturday & Sunday
Ashok Hotel, Chanakyapuri,
New Delhi, India

INVITATION

Dear friends & colleagues,

Greetings from Delhi Ophthalmological Society. We wish to invite you to our 62nd Annual Conference from 15th to 17th April 2011
at Hotel Ashok, Delhi. Indian Ophthalmology is highly advanced and Ophthalmology in Delhi is vibrant and alive. Delhi has perhaps
the maximum number of Ophthalmologists, the largest number of Ophthalmology training institutes and the largest number of
Ophthalmology residents in the world. All subspecialities of Ophthalmology are highly developed and all surgeries-classic and
recent advances are routinely performed.

The Delhi Ophthalmological Society is the Largest State Society in India with over 5000 members and The Annual Conference of our
society is a 3 day celebration of Ophthalmology-live surgeries and wet labs, workshops, instruction courses and free papers showcasing
original research work. Ophthalmologists of International repute participate in this conference. This year our theme is
"Trends in Ophthalmology" and we will be abundantly pleased to welcome you to our conference and our city.

Delhi, the Capital city of India is a modern metropolis with all the world class facilities and a grand historical legacy. A brand new airport,
comparable to the best in the world awaits your arrival. Wide roads and swank radiotaxis provide excellent connectivity. The Delhi
Metro Rail is fast, clean and punctual and there is a fast express link from the airport to the heart of the city. Delhi's air is clean and
highly breathable. It is one of the greenest cities in the world. Your stay will be extremely comfortable. Our hotels are among the world's
best and provide unmatched service. Indian cuisine is appreciated and duplicated the world over and Delhi Restaurants will provide you
with a memorable culinary experience and the taste of India in Delhi.

The comfortable and Airconditioned Shopping Malls in and around Delhi always have a festive atmosphere and your shopping
experience is bound to be incredible. In addition there are the traditional local markets like Karol Bagh and Chandni Chowk to provide you
with the local flavour. Connaught Place in the heart of Delhi is a huge commercial centre built in a circular fashion. It was built by the
British and is an icon for the city. There are number of theaters playing the classical and latest movies from Hollywood and Bollywood.
The Golden Triangle Tour (Delhi-Agra-Jaipur-Delhi) offers you with an opportunity to witness the great Indian heritage.

I wish forward to welcome you to Delhi in the pleasant month of April.

Yours truly

Dr P.V. Chadha Dr Amit Khosla
President, Delhi Ophthalmological Society Secretary, Delhi Ophthalmological Society

Highlights Meet the Masters
Free Paper
Live Surgery Trade Exhibition
Instruction Courses Gala Dinner
Scientific Sessions E-Poster
Video Assisted Courses
Video Stations
Film Festival

SAVE TIME Submit your registration, faculty form & abstract online
for the Annual DOS Conference at

www.dosonline.org

www.dosonline.org 9

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12 DOS Times - Vol. 16, No. 3, September 2010

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Wet Age-related Macular Degeneration Focus

Dr. Dhananjay Shukla, Dr. P. Mahesh Shanmugam, Dr. Muna Bhende Dr. Sanjeev Gupta
MS, MAMS DO, FRCSEd, PhD MS MD, DNB

Age-related macular degeneration (AMD) is a complex multi factorial disease where aging associates with genetic factors and
inflammatory responses. It is one of the major causes of central vision loss. There are different modalities of treatment /treatment
regimens available to manage wet AMD. The treatment strategies have evolved from the period of laser photocoagulation
(transpupillary thermotherapy & photodynamic therapy) which offered only stablization of disease and maintenance of visual
acuity to anti-VEGF era which offers real improvement in visual acuity, implicating in improved visual function and certain degree
of recovery of retinal neuronal network. This focus on wet AMD reviews the current diagnostic/imaging modalities and presently
available treatment and treatment regimens.

(DS): Dhananjay Shukla, MS, MAMS, Professor of Ophthalmology & Consultant, Retina-Vitreous Service, Aravind Eye Hospital
& Postgraduate Institute of Ophthalmology, 1 Anna Nagar, Madurai 625 020, Tamil Nadu.

(PMS): Dr. P. Mahesh Shanmugam, DO, FRCSEd, PhD, Head, Vitreoretinal & Ocular Oncology Services, Sankara Eye Hospitals,
India

(MB): Dr. Muna Bhende, MS, Senior Consultant, Shri Bhagwan Mahavir Vitreoretinal Services, Sankara Nethralaya, 18 College
Road, Chennai

(SG): Dr. Sanjeev Gupta, MD, DNB, Senior Consultant, Siri Fort Laser Eye Centre, 8, Siri Fort Road, New Delhi

(NV): Dr. Naginder Vashisht, MD, FRCS, FICO, Consultant, Sir Ganga Ram Hospital, Rajender Nagar, New Delhi

NV: What are the clinical signs to suspect CNVM? What are • Subretinal hemorrhage
the most common differential diagnosis? • Sub RPE hemorrhage
• Subretinal hard exudates
DS: Recent-onset central visual distortion or loss with • Occasionally intraretinal hard exudates
serous macular detachment of sensory retina or pigment • Occasionally intraretinal hemorrhage
epithelium, accompanied by subretinal blood, hard • Visible subretinal neovascular membrane
exudates or both. Differential diagnosis (D/D) of serous • Right angled venule / chorioretinal anastamosis
macular detachment (SRD) depends on patient’s age: • Drusen in the other eye or some in the eye with pathology
for young patients (< 40 years), the most common D/D Differential diagnosis
is central serous chorioretinopathy (CSC); for older • CNVM of other etiology
patients, age-related macular degeneration is the default • Polypoidal choroidal vasculopathy
diagnosis. In high myopia and traumatic choroidal rupture, • Idiopathic central serous retinopathy
submacular bleed can occur without a CNVM. • Retinal artery macroaneurysm
• Parafoveal telangiectasis
PMS: Recent poor vision unexplained by cataract or other ocular • Macular edema of other etiology
pathology

• Recent poor reading vision

• Scotoma / distortion on Amsler

• Dull macular reflex

• Macular edema

• Subretinal fluid

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• Diabetic macular edema PMS: Color photo

• Post vein occlusion macular edema • Fundus fluorescein angiogram

• Small macular intraocular mass lesions • Optical Coherence tomography

• Intraocular lymphoma with submacular infiltrate • Indocyanine angiogram if occult / mixed / ill-defined
• Choroidal hemangioma CNVM.
• Choroidal melanoma
• Posterior scleritis. MB: Baseline investigations for a patient with CNV:
MB: Clinical signs to suspect CNV include: • Color fundus photograph.
• Presence of a subretinal grayish membrane with fluid, • Fluorescein angiography.
• Optical coherence tomography.
fibrin, exudates and/or subretinal blood. • Indocyanine green angiography if PCV or RAP is suspected.

• RPE irregularity with subretinal fluid and/or hemorrhage. SG: Fluorescein angiography and OCT.

• RPE detachment with blood or adjacent pigmentary NV: What are the features to look for on FFA in wet AMD?

changes. DS: Outline of CNVM (well-defined or ill-defined), presence

• Multiple soft confluent drusen with fresh subretinal of pooling Pigment Epithelial Detachment (PED), pattern

hemorrhage. of pooling (fibrovascular vs. serous PED), presence

• Presence of possible precipitating factors such as myopic of window defects (drusen), presence of intraretinal
degeneration, angioid streaks, patches of healed choroiditis, neovascularization or retino-choroidal anastomosis,
parafoveal telangiectasia, subretinal orange nodules , etc. Retinal Angiomatous Proliferation, (RAP) and staining
(extent of scarring).

Differential diagnosis of CNV: PMS: Lacy hyperfluorescence in early phase of the angiogram,

• Central serous retinopathy, more so in an older patient and visible subretinal network and late leakage in classic
if associated with fibrin. CNVM.

• Polypoidal choroidal vasculopathy – considered as an AMD • Ill-defined late hyperfluorescence or fibrovascular PED

subtype. in Occult CNVM. Fibrovascular PED appears as a slow

heterogenous filling PED, in contrast to a early homogenous

• Retinal angiomatous proliferation – AMD subtype. filling of serous PED. A notch may also be seen wherein

• Hemorrhage due to lacquer cracks in high myopia. the CNVM rests in the notch of the PED.

• Retinal artery macroneurysm. • In the presence of a retinal angiomatous proliferation,
• Vitelliform lesions. a retino choroidal anastamotic vessel can be seen in the
• Diabetic macular edema. early phase of the angiogram, filling with the CNVM and
SG: Dimunition and distortion of vision intraretinal changes such as cystoid macular edema.
• Scotoma in central vision
MB: FFA features to be noted in wet AMD:

• Presence of well defined lacy hyperfluorescence with late
leakage suggestive of a classic CNV.

• Sub retinal and intra retinal hemorrhage \ exudates • Late hyperfluorescence of uncertain origin suggestive of
• Grayish membrane in macula occult CNV.

• Pigment epithelial detachment • Presence of irregular filling of a PED , fuzzy borders or

notching of a PED- fibrovascular PED or RAP.

• Central sensory detachment

• Speckled fluorescence – differentiate occult CNV from

• D\D young patients – central serous retinopathy\ PCV.

hemorrhagic choroiditis\ traumatic choroidal rupture

old patients - diabetic maculopathy, retinal artery • RPE rip – presence of blocked fluorescence in area of rolled

macroaneurysm, macular BRVO. RPE with transmitted fluorescence adjacent to it.

NV: What are your baseline investigations for a patient with • Lesion component – extent of classic , occult, blocked
CNVM? fluorescence due to hemorrhage or fibrin, presence of
staining of scar tissue.
DS: OCT and FFA.
Lesion location – extrafoveal, juxtafoveal, subfoveal.
•

16 DOS Times - Vol. 16, No. 3, September 2010

• Presence of features that may rule out CNV – CSR leaks, NV: What are the features one should look for on OCT to

microaneurysms in DME, retinal artery macroaneurysm, suspect CNVM?

faint stain of drusenoid PED or vitelliform lesions. DS: Perform OCT after FFA. If classic CNV was seen on FFA, look

• Change in appearance after treatment – indications for for macular edema (effect) and subretinal hyper-reflective

stopping, switching treatment, or revising diagnosis. lesion (causative CNV). If occult CNV was suspected, look

SG: Presence of CNVM – its type, location, extent for SRD (effect) and irregular (fibrovascular) PED with
hyper-reflectivity under it. If a PCV was suspected, look

• Presence of RPED – if present look for signs of occult CNV for conical PED (not pathognomonic though); if RAP was

such as notching, irregular filling, late filling suspected, look for intraretinal hyper-reflective lesion with

• Late staining \ pooling retinal edema/without an underlying PED.NB: A scar tissue
is difficult to differentiate from active CNV by OCT alone.

• Presence of RPE rip – intense hyperfluorescence from bare PMS: On OCT, features suggestive of CNVM are
choroids

• Signs suggestive of RAP – small intense hyperfluorescent 1. Presence of a medium to high reflective irregular lesion in

the subretinal space, elevating the overlying retina. Often
dot it may be difficult to define the underlying RPE layer with

NV: What are the common fallacies / diagnostic dilemma the CNVM integrated to it. It may at times be possible to
after FFA? see the breach in the RPE layer through which the CNVM
grows in to the subretinal space.
DS: The most common type of AMD is also the most deceptive:

occult CNV. The main dilemma is D/D between serous 2. subretinal fluid

PED (chronic CSC), fibrovascular PED (occult exudative 3. retinal thickening with intraretinal edema
AMD) and sero-sanguinous PED (polypoidal choroidal

vasculopathy). 4. pigment epithelial detachment

PMS: FFA cannot distinguish between polypoidal choroidal a. serous – base of the pigment epithelial detachment
vasculopathy and occult CNVM. visible

• In the presence of subretinal or sub RPE blood (hemorrhagic b. hemorrhagic – base of the pigment epithelial

PED), FFA will not yield useful information. detachment indistinct and intraretinal growth of

• It may not be possible to localize the CNVM in the presence the CNVM is seen as a high reflective lesion with
of a fibrovascular PED and the lesion size noted on FFA is underlying PED.

larger than the treatable CNVM area. MB: OCT features of CNV:

MB: Diagnostic dilemmas after FFA: • Fusiform thickening at the RPE level – typical of a classic
CNV.
• Well defined hyperfluorescence: Active classic vs fibrotic •
lesion. In the initial stages after treatment, once exudation • RPE reduplication or disruption- suggestive of occult CNV.
resolves, the FFA may show a better defined lesion. Also
once the lesion is composed of mature fibrotic vessels, the PED with associated intraretinal hyperreflective tissue or
vessels appear more prominent, however the late leakage a tubular area of low reflectivity dipping into the deeper
is not pronounced. layers - RAP.

• Speckled fluorescence: occult CNV vs PCV. Here an ICG • Presence of retinal thickening, intraretinal fluid, cystic
spaces, subretinal fluid- signs of activity.
angiography will help differentiate the two.

• PED – AMD vs CSR. The presence of drusen and either • Irregular configuration of PED with high reflective areas
in the sub RPE space – signs of occult CNV.
a notched or irregularly filling PED suggests AMD or its

subtypes. • Bumpy irregular RPE with associated subretinal fluid.

• Intense well defined hyperfluorescence – CNV activity vs SG: Thickening \ fragmentation of RPE-CC layer – CNV
choroidal fluorescence in an eye with an acute RPE rip. Here

the early phase angiograms showing the large choroidal • Presence of sub RPE\retinal and intraretinal fluid – effects

vessels and adjacent blocked fluorescence can confirm the of CNV

rip. • Prescence of intra retinal high reflectivity - RAP

SG: The main problems are in occult CNVM • Multiple RPEDs - IPCV

• Sometimes difficult to even confirm presence of occult
CNV – take photo at 10 -20 min to look for late staining NV: What is the role of ICG in present day scenario?

• May not be able to define full extent of CNV DS: ICG is helpful to diagnose PCV (revealing choroidal
• Difficulty in confirming RAP\ IPCV branched networks and polyps) and RAP (hot spot in
PED, and late CME) in context of wet AMD: PCV has

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better prognosis and RAP has worse prognosis than SG: OCT is not must for diagnosis but is very important for
typical exudative AMD. ICG may have considerable follow up during treatment
though unrecognized role in Indians to detect PCV. We
are ethnically in between African-Americans (where In centers without OCT, follow up treatment can be
most occult CNV are PCV) and Caucasians (AMD rarely based on vision, clinical examination with slit lamp
presents as PCV), and going by Oriental estimates (Japan, biomicroscope. FFA can be done every 2-3 months to check
China and Korea) we may have PCV in 1/3 to 1/4 of our leakage.
occult AMD. PCV lesions should be actively suspected
in occult AMD, and ICG should be performed when NV: Is FFA classification of CNVM relevant to treatment of
indicated by clinical picture (extramacular/juxtapapillary wet AMD in present setting?
CNV, subretinal exudation, sero-sanguinous PED, visible
choroidal polyps) or by FFA and OCT as described above. DS: Yes; I am not aware of any available replacement as yet.
Exact reverse of PCV, RAP is unheard of in Africans, rare OCT can replace FFA for follow-up visits; not for deciding
in Asians and most common (12-15% of exudative AMD) on the initial treatment plan.
in Caucasians.
PMS: Yes. FFA classification allows one to prognosticate and
PMS: ICG is necessary in all cases of occult CNVM to distinguish also decide on the appropriate mode of therapy. An occult
between PCV and occult CNVM and also to define area of CNVM has a poorer visual prognosis as compared to a
treatment in occult CNVM. classic CNVM. Risk of RPE tear exists with occult CNVM.
Suspecting an occult CNVM on FFA may lead to an ICG
MB: Role of ICG: examination and if a PCV were picked up on ICG, PDT
may be necessary.
• Diagnose RAP or PCV.
MB: Relevance of FFA classification of CNV in wet AMD:
• Possible cause of anti VEGF resistance – PCV, arterialized Though antiVEGF monotherapy has been proved to be
feeders. the most effective treatment modality over all subtypes of
CNV, there is still a role for FFA to characterize the lesion.
SG: In cases resistant to anti VEGF injection – revision of For instance, in small occult lesions with good visual
diagnosis or to look for mature vessels acuity, it is preferable to record progression of the disease
before initiating treatment. It is also important to rule
• In cases suspected of RAP\ IPCV out mimicking lesions which may appear like CNV both
clinically and on OCT e.g.CSR with fibrin, retinal artery
NV: What are your suggestions for centres not equipped with macroaneurysm, vitelliform lesions. Personally , it is very
OCT? rare that I would initiate treatment for CNV without FFA
support except in case of known allergy to fluorescein ,
DS: OCT is a huge help but is not indispensible, at least to treat severe renal failure, a pregnant patient or resistance from
wet AMD. FFA is better than OCT to differentiate classic the patient for FFA.
from occult CNVM, to follow up for residual activity and
to determine the extent of scarring. At least some RAP and SG: Yes. It helps to prognosticate – occult CNV has poorer
PCV lesions can be detected clinically and by FFA. Good prognosis. Also in a small occult CNV with good vision,
clinical judgment can replace the need for OCT to some one can wait till there is documented vision drop whereas
extent. in classical CNV, treatment is mandatory.

PMS: It is possible to diagnose AMD based on clinical NV: What are your treatment strategies for extra foveal
examination supported by FFA and also plan the initial CNVM?
treatment. An OCT is however essential for serial follow-up
and further treatment in this era of anti-VEGF therapy. It DS: Before jumping to treatment, I would rule out RAP lesions,
may be possible for an experienced retinal specialist to base which are almost always extrafoveal to begin with, and
further treatment on vision and clinical examination alone acsent a poor prognosis. Standard guidelines are to use
but it may not be appropriate standard of care. Repeating laser photocoagulation. I always prefer transpupillary
an FFA on a monthly basis is improper as well. Hence it thermotherapy (TTT), but add on intravitreal Avastin (stat
would be standard of care to obtain an OCT image of the and PRN) for good measure.
patient.

MB: If OCT facilities are not available, a good slit lamp PMS: If the CNVM is small with the post treatment scotoma
biomiocroscopy with attention to clinical features of CNV possibly insignificant and if the CNVM is classic, I may offer
is sufficient to suspect the same. Once this is done an FFA laser photocoagulation as an option. In an occult CNVM, I
would be able to further characterize the lesion, confirm may not prefer options other than laser photocoagulation.
the diagnosis and plan treatment. In case of post treatment
follow up, improvement in vision along with the clinical MB: Treatment strategies for extrafoveal CNV: This would depend
features of resolution of blood and fluid would suggest a on the size and location. A small CNV well away from the
positive response to treatment. It is always preferable to border of the foveal avascular zone can very well be treated
record the changes on follow up, if possible with a fundus by laser photocoagulation. However, if the membrane is
photograph not only for medicolegal issues but also if one large and the resultant scotoma likely to be disturbing, then
needs to review the diagnosis at a later date. anti VEGF treatment would be preferable. Shrinking the

18 DOS Times - Vol. 16, No. 3, September 2010

lesion further away from the fovea first with an anti VEGF VEGF monotherapy based on the results of the RCTs.
injection may make it more amenable to laser treatment However if there is a small occult lesion with no visual
later. In case of a lesion in the papillomacular bundle, the complaint, I would prefer to review the patient again
option of anti VEGF therapy is preferred. Reduced fluence after 3-4 weeks to confirm progression before initiating
PDT with an anti VEGF injection is also an option in treatment. I still consider combination therapy with
extrafoveal predominantly classic lesions to minimize the reduced fluence PDT as an option in predominantly classic
risk of scotoma formation. lesions, RAP variants where a hot spot is visible on ICG,
PCV lesions, and in some cases of resistant CNV. In classic
SG: In small classic extra foveal CNV, laser photocoagulation lesions where anti VEGF injections cannot be considered,
is the best form of treatment. However, if the CNV is very reduced fluence PDT combined with intravitreal steroid
near the fovea, Anti VEGF injection can be given to reduce would be my preference.
the size of membrane followed by laser photocoagulation.
Large extra foveal CNV or CNV on papillomacular bundle SG: My first choice is Anti VEGF injection monotherapy. After
are best treated with Anti VEGF injections to avoid the first three loading injections, additional injections are
scotoma. given based on OCT and vision, done every 4-6 wks. In
small classical sub foveal CNV, combining Anti VEGF
NV: What is the relevance of laser photocoagulation for extra with low fluence PDT is a good option especially in young
foveal CNVM in the anti VEGF era? patients with idiopathic CNV.

DS: If TTT is not available, combine laser with Avastin. NV: What are the advantages and disadvantages of mono-
therapy versus combined therapy?
PMS: Laser photocoagulation offers a possible cure with a single
session therapy, which is not possible with anti-VEGF DS: Adding PDT to anti-VEGF monotherapy has limited scope;
therapy. It does not have the risk of an intraocular infection adds costs; but probably reduces recurrences. To elaborate:
and is least expensive as well. most AMD lesions are occult and large (poor choices for
initial PDT), one PDT roughly equals 15 Avastin injections
MB: Relevance of laser for extrafoveal CNV in the anti VEGF cost-wise at our institute, and equals Macugen in efficacy
era: This can never be ignored as it gives an option for with PROBABLY less recurrences. Therefore I recommend
total destruction of the lesion with minimal chances of adding PDT as a reserve treatment. For confirmed PCV
recurrence, provided the classic treatment guidelines are lesions, combination therapy probably has a greater value,
followed. VisuaI function need not be compromised in a though I’d start with monotherapy still.
small lesion far away from the foveal center where even the
laser margin remains well away from the FAZ border. It is PMS: Combined therapy theoretically offers lesser retreatments
also a much safer option for patients who are in the high as the advantage when compared to monotherapy. There is
risk category for anti VEGF therapy or when anti VEGF contradicting data regarding this claim that needs further
therapy is contraindicated eg pregnancy, patients with high scrutiny.
risk for thrombo embolic phenomena.
MB: Monotherapy vs combined therapy: I believe this means
SG: Still the best form of treatment in small extra foveal CNV. combination with PDT. In India, the first issue to be
considered is cost as well as ability to comply with the
NV: Elaborate on the treatment strategies commonly followed need for frequent monitoring, both of which take a toll
by you for subfoveal and juxtafoveal CNVM? on the patient and family in terms of finances, travel and
loss of days of work. These issues always take precedence
DS: First and foremost: There is no evidence that any treatment over scientific explanations for relative efficacy of various
helps occult CNVM with good vision and no history of treatment options and tilt the balance one way or the other.
recent drop in vision. Dr. Neil Bressler’s excellent discussion The proven effectiveness of monthly intravitreal injections
of control group of MARINA trial in a recent supplement definitely plays a role in choosing this as the first option, but
of Ophthalmology (Ophthalmology 2009;116:S15–S23 © the perceived attraction, though not proven as dramatically,
2009) should be compulsory reading for all trigger-happy of reduced treatment sessions with combination therapy
ophthalmologists. That said, I prefer monotherapy with may sometimes make this the preferred choice. In stage 2
Avastin or Lucentis: 3 loading doses followed by PRN and 3 RAP lesions as well as PCV, results with combination
injections. For recurrent, refractory and persistent (after 3-6 therapy are definitely superior, but this is not true in typical
injections on individual basis) CNV, I offer photodynamic wet AMD. In monotherapy resistant CNV, combination
therapy as adjuvant. For eyes still unresponsive, I consider therapy would need to be considered.
triple therapy (adding preservative-free triamcinolone to
the cocktail). SG: Except in small sub foveal classical CNV, combination
therapy does not offer any advantage over monotherapy.
PMS: Subfoveal and juxtafoveal CNVM are treated with loading Adding PDT results in increasing the cost of treatment.
dose of anti-VEGF followed by treat and extend protocol. If
there is a frequent need for retreatment and I am unable to NV: Which anti VEGF agent you prefer for your patients and
really practice a treat and “extend” protocol, I may suggest why?
low-fluence PDT in addition.
DS: Avastin, unless contra-indicated. Lucentis, when cost is not
MB: Choice of treatment for sub and juxtafoveal CNV in AMD: a factor. I consider them equal in efficacy, awaiting CATT
My first choice of treatment in a naïve case would be anti (and 4 other trials’) results.

www.dosonline.org 19

PMS: I prefer ranibizumab or bevacizumab and this choice monthly clinical examination and OCT and if stable this
between these two rests with my patient, based on his or period is extended 6-12 weeks progressively. If fluid is still
her financial capabilities. I do not think there is enough present after 3 loading doses, CNV is considered resistant
evidence to suggest FDA approved pan anti-VEGF is any and treated accordingly.
less safe than selective anti-VEGF.
In myopic CNV, since there is a little sub retinal fluid,
MB: Choice of anti VEGF agents: The proven efficacy of leakage on FFA is better than OCT in evaluating the activity
ranibizumab in major RCTS as well as that of bevacizumab of CNV and deciding on re-treatment.
in numerous published reports makes this a difficult
decision. Again this ultimately depends on the patient’s NV: In your opinion what is the role of low fluence PDT as
(and more recently the insurance) willingness to pay initial treatment?
for the treatment as current recommendations include
prolonged follow up with multiple treatment sessions in DS: I have a low opinion for PDT as initial treatment (including
most cases. Once the CATT results are presented, probably for classic CNV), fluence notwithstanding.
the most awaited study in a long time, we would be in a
better position to make the choice for our patients more PMS: I do not consider low fluence PDT as an initial treatment.
aggressively.
MB: Role of low fluence PDT as initial treatment: I do not think
SG: I use either Avastin or Lucentis. The choice is depending PDT as monotherapy has a role at present in AMD except in
on the patients financial status just not for initial loading very rare circumstances. However as combination therapy
doses but for long term treatment. it still may be an option in the situations I have described
earlier.
NV: What is the treatment protocol you follow after initial
management? SG: I donot use PDT alone in management of CNV except if
there is a contraindication for Anti VEGF therapy such as
DS: As explained above. I follow patients at 7-10 days recent stroke\ MI where LF PDT can be combined with
(complication visit), monthly thereafter till resolution of intra vitreal steroids.
CNV, followed by treat-and-extend protocol to reduce
follow-ups. NV: When do you label CNVM as treatment resistant? What
is your protocol in this situation?
PMS: Monthly follow-up during loading dose with evaluation of
distant and near vision, clinical examination, color fundus DS: I have explained my indication for combination and triple
photograph and OCT. This evaluation protocol is followed therapy above. I monitor OCT for vitreomacular traction,
each time the patients visits the clinic during the treat and and if present, could consider vitrectomy (never tried). I
extend protocol. The follow-up is extended by 2 weeks each tend to continue PRN monotherapy after triple therapy
time during the treat and extend protocol. SOS, as long as I keep getting transient recovery, or as long
as the patient can afford it.
MB: Treatment protocol after the first treatment: Monthly
followup with recording of vision, slit lamp biomicroscopy PMS: Absolutely no change / worsening
and OCT for the first three injections, is the standard
protocol I would follow. At the end of 3 months, if the • Subretinal fluid
response is not satisfactory I would repeat the FFA and
maybe perform an ICG as well. Based on the findings I may • Intraretinal edema
opt for switching the anti VEGF agent or using combination
therapy. If the response is good with evidence of resolution • Intra / subretinal hemorrhage
and inactivity clinically and on OCT, I would encourage
the patient to see me after a month to confirm the same. • Vision after 2-3 anti-VEGF injections, I would consider the
Rarely if there is total regression after the first injection CNVM as non-responsive. I change the anti-VEGF, add
and the patient is able to reliably record any change, I intravitreal steroid and low-fluence PDT in this situation.
would observe, but this is extremely rare in AMD unless
one is aiming to quieten down a predominantly scarred MB: Treatment resistant CNV: This term is usually reserved
lesion. After atleast 2 – 3 subsequent monthly visits where for cases with no anatomical and functional response after
the lesion is stable I would increase the interval to 2-3 three initial doses of anti VEGF injections and one would
months and then progressively longer. In case of an active need to revisit the findings at this time. An FFA and possibly
lesion which has shown response to the injections I would an ICG in addition to the OCT would be useful to find
continue monthly evaluations with treatment until the out the possible reason for this resistance. The absence of
lesion is inactive. visual improvement with apparent inactivity on OCT could
be due to fibrosis and atrophy involving the foveal center
SG: Every patient is seen at 5-7 days after injection to look for as well as possible other causes of vision loss not directly
any complication of injection. After the 3 loading dose of related to the CNV. Similarly chronic cystic changes on
Anti VEGF injections, if OCT shows no fluid, no further the OCT may not disappear even with multiple sessions of
injections are given till the appearance of fluid, new treatment and may not be considered as signs of resistance.
hemorrhage or drop in vision. Patients are subjected to
SG: A CNV is considered resistant to treatment if there is no
change on OCT and vision even after 3 loading doses.
Reassess the patient to look for IPCV on ICG angiography.

20 DOS Times - Vol. 16, No. 3, September 2010

One can consider changing Anti VEGF agent or adding less response to treatment after an initial good response

PDT in these cases. may point towards the need to switch therapies. It would

NV: What should be the OCT follow-up parameters for be pertinent to distinguish between resistant and recurrent
CNVM – intraretinal edema / subretinal fluid / PED? CNV when planning treatment.

SG: Appearance of new hemorrhage
DS: All three are valid parameters depending on the type

of CNV, though I would give greater weight to intra- or • New area of leak on FFA

subretinal fluid than to PED. • Recurrent CNV after laser photocoagulation of extra foveal

PMS: Reduction in subretinal fluid during initial injections and CNV – repeat laser if recurrence extra-foveal

complete drying up subsequently. • Sub and juxta foveal recurrences – monotherapy with Anti

• Reduction of intraretinal fluid VEGF agents.

• Decreased height of PED after initial injections with NV: What are the management options for patient with wet

stabilization of vision, drying up of subretinal and AMD and submacular hemorrhage / break through

intraretinal fluid. Subsequent flattening of PED. vitreous hemorrhage?

• I look at the morphological features on OCT rather than DS: Depends on extent of bleed. If extent and nature of CNV
the numbers – if one were to insist on numbers, reduction is discernible, I would continue treatment as if there is no
by 50 microns of retinal thickness on a scan, meticulously blood. If subretinal or breakthrough blood is large and
repeated at the same location as the initial scan can be covers macula, with recent visual loss attributable to bleed,
considered as response. I would consider intravitreal expansible gas injection (have
obtained good results with 0.3 cc pure C3F8). Consider
MB: OCT parameters for follow up: Signs of activity include vitrectomy if intravitreal bleed doesn’t clear with gas.
retinal thickening, intraretinal fluid, cystoid spaces,
subretinal fluid and PED. Disppearance of these indicates PMS: Situations
response to treatment. It is usually the subretinal fluid and
PED which resolves first followed by intraretinal fluid and • Large submacular hemorrhage (subretinal and not subRPE)
then cystoid spaces. Note should also be made of additional with minimal vitreous hemorrhage – intravitreal anti-
features such as RPE rip , ERM formation, vitreomacular VEGF with pneumatic displacement
traction and foveal thinning. Macular hole formation has
also been reported following treatment for CNV. • Fresh significant vitreous hemorrhage in a patient
previously known to have AMD – ultrasonogram to rule
SG: Sub retinal fluid/ intra retinal fluid/ PED fluid – in order of out retinal detachment, intravitreal anti-VEGF and review
importance. Sub RPE fluid is most resistant to treatment. 4 weeks later. If no significant clearing of the vitreous
If the sub retinal and intraretinal fluid have disappeared, hemorrhage, can consider vitrectomy with anti-VEGF
additional injections should not be given for only stable
sub RPE fluid. • Presence of large peripheral hemorrhagic choroidal
detachments on ultrasonography – intravitreal anti-VEGF,
NV: How do you diagnose recurrent CNVM? How do you close follow-up to abort occurrence of angle closure,
manage them? serial ultrasonography to look for resolution of choroidal
detachment and vitrectomy and further anti-VEGF for
DS: Besides the above 3 parameters (Q18): new subretinal blood. clearing vitreous hemorrhage.
A drop in vision with no change in macular morphology
does not qualify. Management already explained. In all the above situations, FFA / ICG will need to be
performed after spontaneous absorption or post-surgical
PMS: A recurrent CNVM is when the CNVM recurs after a removal of vitreous hemorrhage.
treatment free interval and can be diagnosed with clinical
examination, FFA and OCT. The treatment is restarted MB: Management options for wet AMD and submacular
with anti-VEGF loading dose, treat and extend protocol hemorrhage / beakthrough vitreous hemorrhage: This is
and low-fluence PDT. more common in PCV where massive vitreous, subretinal
and even suprachoroidal hemorrhages have been reported
MB: Recurrent CNV – diagnosis and management: A CNV than in typical wet AMD.
which has typically occurred at the edge of a laser or PDT/
TTT scar is what has been traditionally referred to as a • In case of a fresh (less than 1 week)submacular hemorrhage,
recurrent CNV. In the anti VEGF era it would probably be pneumatic displacement of the blood followed by treatment
a CNV that has initially responded to treatment and shows of the CNV or polyp shows good results.
evidence of increased size and activity after a period of
quiescence. The presence of a prior good response would • If the hemorrhage is more than a week old, the results may
probably encourage one to continue the same line of not be as satisfactory due to toxic effects of the blood.
treatment, though a small recurrence at the extrafoveal edge
of a scar may do well even with laser photocoagulation. The • Sub RPE hemorrhages do not respond well to pneumatic
phenomenon of tachyphylaxis where there is progressively displacement and are hence not an indication for the
procedure.

www.dosonline.org 21

• The role of intravitreal TPA is questionable. choroid is clinically visible. OCT shows a flattened PED

In case of vitreous hemorrhage where ultrasound and loose huddled-up RPE at one edge of the PED. FFA
documents a submacular hemorrhage, vitrectomy may be shows hypofluorescent (black) strip of rolled up RPE and
performed under a very guarded prognosis, more so if there intense hyperfluorescence over exposed choroid.

has been documented poor vision from a macular scar or PMS: Clinically presence of a subretinal elevated lesion, adjacent

large CNV earlier. Following clearing of the hemorrhage to which a well-defined area devoid of RPE can be seen. In

it may be possible to identify and treat the CNV or polyp addition a sudden increase in subretinal fluid can be noted.

with either laser, PDT or anti VEGF injections. On FFA, an area of hypofluorescence adjacent to which an

SG: Wet AMD with large submacular hemorrhage – Try to area of well-defined hyperfluorescence can be seen in the

displace blood with intravitreal gas with or without TPA. early phase of the FFA with leakage in the late phase if the

This is followed by AntiVEGF monotherapy. Sub RPE bleed RPE tear is acute.

does not respond to pneumatic displacement. On OCT, a scrolled RPE layer with adjacent area without

• Wet AMD with vitreous hemorrhage RPE can be seen with subretinal fluid.

• Mild – monotherapy with Anti VEGF MB: RPE tears:

• Severe – Vitrectomy with Anti VEGF injections. • Clinical findings – scrolled up area of RPE with an adjacent
area of bare choroid – typically crescentic in shape , may
NV: What are frequently encountered treatment compli- be associated with significant subretinal fluid in the acute
cations? phase. This feature typically occurs either spontaneously or
following treatment of a very tense PED. The FFA findings
DS: Subretinal bleed, with/without retinal pigment epithelium • have been described earlier . OCT shows a discontinuity
tears (rip). Uveitis, endophthalmitis and ocular hypertension in the RPE at the site of the rip.
are also rarely seen.
Management – in the acute phase, this is best observed. The
PMS: Retinal pigment epithelial tear in occult CNVM sudden exposure of a large area of choriocapillaris leads to
increase in exudation that spontaneously reduces by about
RPE atrophy with PDT a week. If there is no active CNV, no treatment is indicated.
If there is an active CNV one can proceed with treatment
Rarely endophthalmitis. directed towards the CNV. Visual prognosis is good if the
tear does not pass through the foveal center.
MB: Frequently encountered treatment complications: Related
to the procedure, the drug or the disease process itself.

• Procedure related complications include allergic response SG: Clinically one can see the curled up RPE and a crescentric

to either the topical anesthetic or povidone iodine, injection shaped bare choroid. FA and OCT also help in confirming.

site pain,hemorrhages , post treatment inflammation and FA shows intense hyperfluorescence in area of bare choroids

infection. starting in early phases. OCT shows discontinuation of RPE

• Increase in subretinal or even breakthrough vitreous layer with curled margin.Treatment remains Anti VEGF
hemorrhage has been reported following laser, PDT and monotherapy in the prescence of active CNV.

anti VEGF agents. Tense PEDs run the risk of developing NV: What is Retinal Angiomatous Proliferation (RAP)? What

RPE rips post treatment. are clinical signs to pick up RAP?

• Intravitreal silicone oil droplets have been reported to cause DS: RAP is a sub-type of AMD which arises within retina,

disturbing floaters and the source has been attributed to also called type 3 neovascularization (cf.- type 1: occult or

the syringes used for the procedure. sub-RPE neovascularization; type 2: classic or subretinal

• Systemic risks due to absorption of the anti VEGF agents neovascularization, which has broken through RPE from
such as thromboembolic phenomena. These however are choroid). Clinical features include intra-retinal bleed in
rare with proper case selection. an extrafoveal AMD in an older than usual patient with/
without a PED; retino-choroidal anastomosis may be visible

SG: Sub retinal bleed later (stage 3). RAP looks a lot like parafoveal telangiectasia.
• RPE tear Diagnosis is confirmed by FFA and ICG as explained above.
80% patients develop RAP in fellow eye after 1 year (cf.-

• Injection site inflammation 43% incidence of exudative AMD in the fellow eye within
5 years).

• Rarely uveitis, endophthalmitis, Ocular hypertension PMS: It is a variant of AMD wherein the CNVM extends in to

NV: How do you diagnose and treat retinal pigment the retina as well. Clinically predominant retinal changes
epithelium tear? such as intraretinal hemorrhage, hard exudates, cystoid
macular edema in addition to subretinal fluid and pigment
DS: Suspect rips in all sudden subretinal bleeds, especially epithelial detachment can be seen.
in the background of a large PED. Sometimes exposed

22 DOS Times - Vol. 16, No. 3, September 2010

MB: RAP lesions: NV: Is there an end to the injection menace?

• Definition: Type 3 neovascularization, a subtype of AMD. DS: You probably mean “endless anti-VEGF injections.” A

Here the neovascularization is intraretinal to start with and million dollar question: several trials of long-acting drug

progresses subretinally to finally result in a retinochoroidal depots, radiation therapy and topical drugs (anti-VEGF and

anastomosis. NSAIDs) are trying to answer it. NB: I stop the injections

• Clinical signs: anyway, even without complete resolution, when the
CNVM becomes more than 50% scarred; when it becomes

• Stage 1: Intraretinal hemorrhages with CME very extensive (and therefore untreatable); or when Snellen

visual acuity drops below 3/60 (with a 6/12 or better fellow

• Stage 2: Dipping vessel at the site of the lesion with eye).

evidence of CNV formation. At this stage the ICG

may identify a hot spot. PMS: Future holds hope with alternate approaches to make

the anti-VEGF last longer, target the VEGF pathway at a

• Stage 3: Vascularized or notched PED with a proximal level, alternate anti-VEGF agents, implants, oral

retinochoroidal anastomosis . This is seen as notching anti-angiogenic agents.

on FFA and a clearly defined network in the area of

notch on the ICG. MB: Injection menace? I think this may be too strong a term as

for the first time we are able offer our wet AMD patients

SG: Described in 1992 as a deep retinal vascular anomalous the possibility of visual improvement. However if used

complex. Later modified to include retinal choroidal irrationally across the board it becomes frustrating to

anastomoses, particularly in the setting of pigmented the patient leading to “window shopping” as well as

epithelial detachments medicolegal problems. As in any treatment modality,

• Stage I, intraretinal neovascularization (IRN)- This stage is proper case selection after a thorough evaluation and
often accompanied by intraretinal hemorrhages and edema adherence to a logical treatment regimen is essential. I am
sure that we will soon be able to streamline our treatment

• Stage II consists of subretinal neovascularization (SRN)- A strategies in AMD to reduce injections to an optimal

localized, neurosensory retinal detachment develops with minimum and maybe hope for a less invasive treatment

increasing intraretinal edema, intraretinal and preretinal in the future.

hemorrhages, as well as an associated serous pigment SG: All new treatment strategies are aimed at reducing the

epithelial detachment (serous-PED) number of injections. In future, combination therapies with

• Stage III describes choroidal neovascularization seen different drugs or laser or radiation or intravitreal impant

clinically and angiographically, sometimes in association may result in decreasing the number of injections.

with vascularized-PED.

• Prescence of intra retinal or pre retinal hemorrhage should
make you suspicious of RAP. ICG angiography shows hot
spots in mid to late phases.

NV: How do you treat RAP? DOS Correspondent
Naginder Vashisht MD, FRCS, FICO
DS: No specific strategy beyond what is explained above. We
don’t see it commonly enough to formulate a focused
regimen. I would definitely perform TTT for an extrafoveal
RAP.

PMS: RAP can be treated with anti-VEGF but may need steroids
in addition and PDT.

MB: Treatment of RAP: In the early stages where the proliferation
is intraretinal and CME is the predominant finding, there
is a rapid and good response to both intravitreal steroids
and anti VEGF agents. However in the later stages the
response is not as good and most studies underscore the
need for combination therapy using PDT and intravitreal
antiVEGF or steroid. Conventional laser may be an option
for a small extrafoveal RAP lesion.

SG: In stage I, focal laser of extra foveal hot spot can be done.
In late stages, these can be managed with intravitreal Anti
VEGF agents with or without PDT or laser photocoagulation
of extra foveal hot spot.

www.dosonline.org 23

Precautions for Cataract Extraction in Cataract
HIV Positive Cases

Kamaljeet Singh MS, Varun Kharbanda MBBS

Healthcare workers (HCWs) have always been exposed to Precautions for the surgeon
the risk of infection following contact with the patients'
body fluids6. This is particularly true of surgeons, anaesthetists, Surgeons and his team operating on a patient with known HIV
and scrub nurses in the operating theatre. Indicative of this is infection or on potentially infected patients should be aware of the
the incidence of 28.4% of a positive response to the presence of risk of transmission of infection and the precautions to be taken
Hepatitis B virus (HBV) antibody among surgeons compared with to prevent it. In 1987, the CDC issued guidelines for minimizing
that of the general population between 3 and 5%7. Similar is the the risk of HIV transmission in health care setting, which are
case with HIV, with new HIV infections occurring worldwide and be called the "Universal Precautions”*. In fact it is advisable to
better availability of low cost antiretroviral drugs the number of practice these precautions in all the patients regardless of their
the HIV-positive people in the population is steadily increasing. HIV status. These include5:
Surgeons will be increasingly called upon for consultation and
surgical interventions for routine surgical conditions including • Hand-washing before and after all medical procedures.
cataract surgery. It has been estimated that a surgeon working in
an area with high prevalence of HIV over a career span of 30 years • Safe handling and immediate safe disposal of sharps:
has as high as 1:4 chance of acquiring the infection8. not recapping needles; using special containers for sharp
disposals; using needle cutter/destroyers; using forceps
This article deals with important aspects that an ophthalmologist instead of fingers for guiding sutures; using Vacutainers where
should keep in mind while operating an HIV positive patient for possible.
cataract, which if followed correctly lead to the work environment
being much safer for the surgeons, the support staff as well as • Safe decontamination of instruments.
the patients. As such the chances of getting infected by a needle
prick injury, which is by far the most common form of exposure • Use of protective barriers whenever indicated to prevent
to surgeons, is 0.3% while through the other common route i.e. direct contact with blood and body fluid such as gloves,
Mucous membrane splash to eye or oro-nasal is about 0.09%9. Add masks, goggles, aprons, and boots. A HCW who has a cut or
to this the fact that cataract surgery now a days is almost a blood abrasion should cover the wound before providing care.
less surgery, in addition to being careful if we just follow these
simple suggestions we can bring the infection due to exposure • Safe disposal of contaminated waste.
down to an even more negligible rate.
*These apply to any setting where there is handling of potentially
Preoperative evaluation infectious materials like blood, other body fluids containing visible
blood, semen, and vaginal secretions, cerebrospinal, synovial,
From a surgeon’s point of view we should carry out a routine pleural, peritoneal, pericardial, and amniotic fluids, Universal
evaluation for HIV patients as for any other surgery. CD4 counts precautions do not apply to feces, nasal secretions, sputum, saliva
and plasma viral loads, in addition to the standard laboratory sweat, tears, urine, and vomitus unless they contain visible blood.
tests, are useful in determining the prognosis in AIDS patients.
Reduction of the HIV viral load in the plasma prior to high- Hand-washing
risk interventions like cardiothoracic and orthopedic surgery
have been tried to ensure the safety of the operating team10. There is no Health precaution like Hand washing. Washing with
Postoperative CD4 counts of 200 cells/mm3 or less are associated simple toilet soap reduces the rate of transmission of common
with higher-mortality rate11 and so are postoperative viral loads infections including HIV. In most circumstances non medicated
>75,000 RNA copies/m12. Although these figures may be true for soaps and detergents are effective in removing most transient
highly invasive surgeries as mentioned above, how big a role CD4 contaminants. In demanding circumstances like in case of
counts and viral loads play in a cataract surgery have not been handling an HIV positive patient, ethyl alcohol or Isopropyl
studied in details. alcohol can be used. We can also use detergent formulations
containing Chlorhexidine Povidone, or Hexachlorophene.
From an ophthalmologist’s point of view there are a number of
co morbid ophthalmological conditions which might require Given below is a simple diagram showing the correct method to
intervention along with the cataract extraction as well. The few wash our hands (Figure 1):
important ones are mentioned below (Table 1).
Safe handling and disposal of sharps
Regional Institute of Ophthalmology
M.D. Eye Hospital All used needles and sharps should be deposited in thick walled
puncture resistant containers. Bending, Reshaping, should be
Allahabad, Uttar Pradesh prohibited as should be recapping the needles to avoid needle
stick injures. All used disposable syringes and needles should
be discarded into bleach solution at the work station before final
disposal. Perhaps the most effective strategy is to transfer sharp
instruments on a kidney dish and not directly from hand-to-
hand13. The basic idea here is that more the amount of time that a
used needle is rotated or passed more are the chances of someone

www.dosonline.org 25

Table 1: Co morbid conditions that an ophthalmologist has to rule out in an HIV patient

Adnexal manifestations Herpes zoster ophthalmicus, Kaposi sarcoma, Molluscum contagiosum, trichomegaly.
Anterior segment manifestations
Conjunctival microvasculopathy, Keratoconjunctivitis sicca,
Posterior segment manifestations
Infectious keratitis (Varicella-zoster virus, Herpes simplex virus, Fungal,
Microsporidia), Iridocyclitis .

HIV retinopathy, HIV-related retinochoroiditis, Cytomegalovirus retinitis,
Acute retinal necrosis, Progressive outer retinal necrosis, Syphilis, Tuberculosis,
Pneumocystis carinii choroidopathy, Toxoplasma retinochoroiditis, Histoplasma
chorioretinitis, Cryptococcal chorioretinitis.

Figure 1: Pictorial discription of the Figure 2: Surgeon wearing two pairs of well fitting gloves
proper way to wash hands

getting accidentally pricked therefore we should try to keep the Chemical Methods of Disinfection: For heat labile article and
handling of used needles to a minimum. surfaces which cannot be sterilized or boiled, it is necessary to
employ the chemical methods. Various chemical agents that can
Safe decontamination of instruments and surfaces be used in this respect are;

Wherever possible, single disposable equipment and materials 2% glutaraldehyde for thirty minutes is used for decontamination
should be employed in clinical procedures. Any equipment of sharp instruments, it can also be used for instruments like
which is to be reused must be sterilized or disinfected before tonometers, gonioscopes, capsulotomy lenses as well as for
reuse. Reusable equipment must be of a type that is easily anesthetic tubing etc when ever they are used on HIV positive
decontaminated without damage to its function. Manufacturer’s patients.
instruction must be consulted to ensure compatibility of materials
with the methods of decontamination employed4. Fresh aqueous solutions of sodium hypochlorite (BLEACH)
of concentration 10,000 parts per million (PPM) or sodium
Decontamination Methods dichloroisocyanurate granules are recommended for table and
floor surface disinfection. It is advisable never to wipe the spillage
Persons/workers undertaking the decontamination procedure with a wet mop as it might further spread the microbes, in case
must wear protective clothing including gloves. of a spill. The spilled blood should be completely covered either
by sodium dichloroisocyanurate granules or by towel treated with
Sterilization: HIV viruses are susceptible to heat. Wherever soduim hypoclorite solution. A few minutes must elapse before
possible equipment must be sterilized by conventional heat or the towels are cleared and disposed as clinical waste.
dry heat. Recommended minimum temperature and hold times
for achieving sterilization are 134°C for 3 minutes or 126°C for *If someone wants to perform Phacoemulsification in a known HIV
10 minutes, or 121°C for 15 minutes or 115°C for 30 minutes. (+ve) person, it should be done with a Phaco machine of newer
Autoclaving is also advised as the most ideal procedure for generation which does not need any internal tubing system and
decontaminating Linen. preferably to be done as a last case in that OT. If the Phaco machine
has internal tubing system, it should be properly sterilized after
Physical Method of Disinfection: The HIV virus are inactivated by doing Phaco procedure and to be done as a last case for that OT
immersion in boiling water although it is stressed that it can not be in that machine. It is better to do surgery under topical anesthesia
relied upon to inactivate bacterial spores. The cleaned instruments with clear corneal section.
must be completely immersed in water at 1000C and any air
bubbles dislodged. Item should be left for at least five minutes.

26 DOS Times - Vol. 16, No. 3, September 2010

Table 2: Showing different methods of disinfection used in Use of protective barriers
our department for all the instruments used while operating
an HIV positive patient Protective barriers while operating a HIV positive patient consists
mainly of gloves, eyewear, mask and cap, foot wear and impervious
Instrument Decontamination Method gown.

Irrigating vectis 2% Glutaraldehyde (30 mins) Gloves
Irrigation-aspiration
two-way canula 2% Glutaraldehyde (30 mins) Use of double gloves (fivefold reduction of risk of skin
Iris repository 2% Glutaraldehyde (30 mins) contamination)13,14 or special prick proof gloves13 help in
Sinsky’s hook intraocular preventing needle pricks or pricks from sharp bone fragments
lens dialer 2% Glutaraldehyde (30 mins) or snagged wires. We should also make sure that the gloves are
Universal eye speculum 2% Glutaraldehyde (30 mins) well fitting because tight gloves tend to get punctured very easily,
Arruga’s needle holder 2% Glutaraldehyde (30 mins) whereas loose gloves makes handling the instruments difficult
Superior rectus holding which again gives rise to higher chances of inadvertent needle
forceps 2% Glutaraldehyde (30 mins) pricks.
Saint Martin’s forceps 2% Glutaraldehyde (30 mins)
Conjunctival sac scissors 2% Glutaraldehyde (30 mins) Eyewear
Vannas’ scissors 2% Glutaraldehyde (30 mins)
Plain dissecting forceps 2% Glutaraldehyde (30 mins) Various forms of combined eye and face protection are available.
Canulas 2% Glutaraldehyde (30 mins) Basic requirement is to give complete coverage of eyes when
MacPherson’s forceps 2% Glutaraldehyde (30 mins) splashing of blood or body fluids is likely to occur, although this
Blades ( no. 15 , no. 11) Disposable single use generally does not happen with cataract surgery, still one should
Cresent knife Disposable single use never take a chance with an HIV positive patient If this risk is
Angular keratome Disposable single use high it is preferable to use disposable eye protector.
Cystitome Disposable single use
Side-port blade Disposable single use Mask and cap
Glass syringes Autoclave
Head wear in common use by operation room personnel does
not offer complete protection against contamination of blood
splashes. Special protective hood are available which offer better
protection from blood and body fluid splashes. Masks to cover
the oral mucosa work well to protect in the same way as protective
eyewear and caps do.

Foot wear

Fenestrated foot wear: must never be worn in situation where
sharps are handled. It is recommended that Wellington boot or
calf length plastic over boots are worn rather than shoes or clogs.
Footwear is also to be adequately decontaminated.

Impervious gown

There are several waterproof fabrics with the ability to breath
available for use and are comfortable to wear. In our institute we

Figure 3: Both the surgeon and the assistant shown wearing the impervious gown 27

www.dosonline.org

Table 3: Summary of Do’s and Don’ts

Do’s Don’ts

Remove gloves, if appropriate Do not panic

Wash the exposed site Do not put the pricked finger

thoroughly with running in mouth

water

Irrigate with water or Do not squeeze the wound
saline if eyes or mouth to bleed it
have been exposed

Wash the skin with soap Do not use bleach, chlorine,
and water alcohol, betadine, iodine or
other antiseptics/detergents
on the wound

Figure 4: Proper method of disposal after Counseling and antiretroviral therapy.
the procedure is over
• Pretest counseling to the exposed individual.
use a protective gown that is issued by the government of India
and it comes complete with protective headwear, mask, eyewear • Baseline test for HIV.
and footwear, with two layers of well fitting gloves.
• Post Exposive Prophylaxis (PEP) with antiretroviral
Management of cuts and bruises on skin medicines should be started within an hour of the injury
where possible when the source patient is known to be HIV
The risk following non-intact skin exposure has been estimated positive or comes from a high-risk group and the HIV status
to be less than the risk of mucous membrane exposure (0.09%)9 is unknown and the exposure is of high or intermediate risk
while those following exposure to other fluids and body tissue are in nature. PEP may also be considered for those presenting
overall lower than that of exposure to blood. It is advisable that all 72 or more after exposure after explaining the risk/benefit.
skin defects should be covered with waterproof dressing before Details of PEP are given elsewhere17.
the procedure and then the gloves be worn.
Reporting and documentation of the event
Safe disposal of contaminated waste
• Record date/time of exposure and details of the event.
Wastes should be disposed of in accordance with the established
institutional policy. Medical wastes should be discarded into • Details of the exposure source if known.
red plastic bags with minimal handling. They should be sent for
incineration or stored in a designated location to be collected • Details of the PEP treatment if given.
later. Needles and sharps should be discarded into puncture proof
bags. While any item that has had contact with blood, exudates, or • Follow-up and outcome.
secretions may be potentially infective, it is not usually considered
practical or necessary to treat all such waste as infective15,16. Our experience
Infective waste, in general, should either be incinerated or should
be autoclaved before disposal in a sanitary landfill. Bulk blood, We have operated on 4 eyes of 3 patients out of which 2 patients
suctioned fluids, excretions, and secretions may be carefully were on ART, for 7 years and 3 years, respectively and both
poured down a drain connected to a sanitary sewer. Sanitary having their CD4 counts < 200 whereas the third was a recently
sewers may also be used to dispose of other infectious wastes diagnosed case of HIV with CD4 count of >300. The results of all
capable of being ground and flushed into the sewer. the operations have been good with all three getting BCVA >6/12.
The surgeon did not report hindrance in viewing the microscope
What to do in case of exposure through the hood as well as no restriction in movements even
after wearing the gown and extra gloves. Apart from the surgeon
There are a few do’s and do not’s that a surgeon should follow in even the OT staff have become well accustomed to the extra care
case of exposure5. These are given in Table 3: and precautions that have to be taken while operating an HIV
positive patient.
In addition to the above precautions one must also do a prompt
assessment of the risk, i.e., the source, recipient, and the nature Conclusion
of exposure17
Operating a cataract in an HIV patient is technically no different
• Source: HIV testing after proper consent. If known to be HIV then operating a normal individual. Still we see that often surgeons
positive then assess the health status and the possibility of are apprehensive about operating on HIV patient. In this article
drug resistance if on anti retro-viral therapy. we have discussed some simple and straight forward precautions,
understanding of which would make things much easier and
• Recipient: Baseline serological testing for HIV. simpler for both the surgeon and the patients.

• Nature of exposure. References

1. Centers for Disease Control. Recommendations for prevention of
HIV transmission in health-care settings. MMWR 1987;36 (suppl
no. 2S)

28 DOS Times - Vol. 16, No. 3, September 2010

2. L.Perugia and G.C.Traina et al.AIDS and Surgery. International 12. Tran HS, Monocure M, Tranoff M, Goodman M, Puc MM, Kroon
Orthopaedics (SICOT) (1994) 18:397-399 D, et al. Predictors of operative outcome in patients with human
immunodeficiency virus infection and acquired immunodeficiency
3. Prosanta K R Bhattacharjee. Human immunodeficiency virus from syndrome. Am J Surg 2000;180:228-33.
the surgeons' viewpoint. Ann Trop Med Public Hlealth 2008;1:35-42.
13. Wright JG, Young NL, Stephens D. Reported use of strategies by
4. Bhatt, Janardan V. H.I.V infection risk in clinical set up and surgeons to prevent transmission of bloodborne diseases. Can Med
practicing healthy methods of prevention. Gujarat Medical Journal, Assoc J 1995;152:1089-95.
(1999) 56 (03). pp. 41-45. ISSN 0971-9342.
14. Patterson JM, Novak CB, Mackinnon SE, Patterson GA. Surgeons'
5. NACO Antiretroviral Therapy Guidelines for HIV-infected Adults concern and practices of protection against blood borne pathogens.
and Adolescents Including Post-exposure Prophylaxis (2007) ; 67-97. Ann Surg 1998;228:266-72.

6. Davis JM, Demling RH, Lewis FR, Hoover E, Waymack JP The 15. Garner JS, Favero MS. Guideline for handwashing and hospital
surgical infection society's policy on human immunodeficiency environ- mental control, 1985. Atlanta: Public Health Service,
virus hepatitis B and C infection. Arch Surg (1992) 127:218-221. Centers for Disease Control, 1985. HHS publication no. 99-1117.

7. Buergler JM, Kim RK, Thisted RA, Cohn S J, Lichtor JL, Roizen 16. CDC. Human T-lymphotropic virus type III/lymphadenopathy-
MF Risk of human immunodeficiency virus in surgeons, associated virus: Agent summary statement. MMWR 1986;35:540-2,
anesthesiologists and medical students. Anesth Analg (1992) 75: 547-9.
118-124.
17. Centers for Disease Control (CDC). Updated US public health
8. Allen-Mersh TG. Acquired immunodeficiency syndrome. In: Russel services guidelines for the management of occupational exposures to
RC, Williams NS, Bulstrode CJ, editors. Bailey and Love's short HIV and recommendations for post exposure prophylaxis. MMWR
practice of surgery. 24 th ed. London: Arnold; 2004. p. 175-82. Morb Mortal Wkly Rep 2005;54:1-17.

9. Saltzman DJ, Williams RA, Gelfand DV, Wilson SE. The surgeon First Author
and AIDS: Twenty years later. Arch Surg 2005;140:961-7. Kamaljeet Singh MS

10. Regez RM, Kleipool AE, Speekenbrink RG, Frissen PH. The risk of
needle stick accidents during surgical procedures: HIV-1 viral load
in blood and bone marrow. Int J STD AIDS 2005;16:671-2.

11. Savioz D, Chilcott M, Ludwig C, Savioz M, Kaiser L, Leissing C.
Preoperative counts of CD4 T-lymphocytes and early postoperative
infective complications in HIV-positive patients. Eur J Surg
1998;164:483-7.

www.dosonline.org 29

Key Challenges in Restoring Sight to Cataract
Children with Cataract

*Subodh Kumar Sinha MS, MSc (CEH), **Rajesh Noah MBBS, MCH, *Gaurav Kakkar MS

Globally there are an estimated 1.4 million blind children Many of the hospitals which provide paediatric eye care services
and almost three quarter of them live in the developing are located in bigger cities and many children, particularly those
countries1. The prevalence of blindness in children varies from residing in rural and remote areas do not have access to eye care
approximately 0.3/1000 children in affluent countries to 1.5/1000 services. The children along with family members have to travel
in the poorest communities2. The control of blindness in children long distances to reach the hospitals.
is a high priority within the World Health Organization (WHO)
and International Association for Prevention of Blindness (IAPB) Cost of treating a child with cataract at a tertiary level centre is an
global initiative: VISION 2020 — The Right to Sight programme3,4. issue considering the fact that the surgery need to be conducted
under general anaesthesia, requires preoperative investigations;
The proportion of blindness in children due to childhood cataract consumables are expensive making the treatment unaffordable
varies considerably between regions from approximately 10-30% to many parents.
with a global average of 14%, giving 190000 children blind from
cataract5. Fear of loss of life of the child due to complication of general
anaesthesia or fear of loosing the eye permanently also prevents
Childhood cataract is the most common treatable cause of the parents from accessing cataract surgical services. Even if the
childhood blindness. In developing countries like India, surgery is offered free of cost, there will be poor acceptance for
proportion of childhood blindness due to cataract varies from surgery in absence of appropriate counselling.
10-12% amongst children from schools for the blind6,7,8 to 43%
in population based studies9. Regular and long term follow-up is mandatory in all children
operated for cataract .Management of amblyopia, proper refraction
Challenges in control of Childhood blindness due to cataract and low vision assessment and management of posterior capsular
opacification are crucial for restoring sight in children blinded
Services for childhood cataract and other causes of childhood due to cataract. Poor counseling of the parents or family members
blindness are mostly provided by Child Eye Health Tertiary cost of follow-up visits and unfelt need are some of the barriers
Facilities (CEHTFs) in Government, Private and NGO sectors. for poor follow-up.
The challenges in restoring sight to children with cataract in this
region can be divided into Service Provider related challenges

• Child-Related/Community related There are many tertiary level centres in big cities in government,
private and NGO sector providing services for childhood cataract
• Service Provider related but most of the primary eye care (PEC) activities conducted by
these centres are focused on adult cataract. Most of the centres
Child-Related/Community related challenges wait for the children to come to the hospitals and there is lack of

Lack of awareness of the community and amongst parents and
family members is the one of the key challenges. This is particularly
common in rural population and urban slums. Illiteracy,
particularly in women, and poverty worsens the situation. These
factors make it difficult for the family members to find out whether
the child is blind or not.

This is further complicated by many traditional beliefs preventing
the parents from seeking eye care services for the child with
cataract. Sometimes the family members don’t want other
members of the society to find out that their child is blind and
this causes further delay in seeking treatment.

Many parents are unaware about the treatment of childhood
cataract and usually prefer some kind of non-surgical treatment
leading to loss of valuable time for early treatment required in
many children with cataract.

* Venu Eye Institute & Research Centre Figure 1: Child being screened for ocular morbidity
1/31, Sheikh Sarai Institutional area, Phase -2, New Delhi -17 in a screening camp

**Vision 2020 the Right to Sight India

www.dosonline.org 31

Sometimes the primary health workers themselves are unaware
about accepted guidelines about the referral need, its urgency and
facilities available.

Strategies to overcome the challenges in restoring sight to
children with cataract

Figure 2: Child with bilateral cataract Childhood blindness due to cataract can be addressed by adopting
waiting for surgery a multidisciplinary approach and forming a team which takes
care of different activities required to provide comprehensive eye
care. Vertical linkages and networking with other organizations
providing primary health/eye care, rehabilitation and education
services can help to overcome the challenges in restoring sight to
children with cataract.

Following strategies at different stages can be adopted in our
setting to achieve the VISION 2020 goals of providing appropriate
surgery to all children with congenital cataract with immediate and
effective optical correction, in suitably equipped specialist centres.

• Raising level of awareness

• Detection and referral of child with cataract to the appropriate
treatment facility

• Getting the child to hospital

• Surgery of child with cataract

• Post –surgical follow-up

Figure 3: Cataract surgery in a child under progress • Networking
Raising awareness

any community to hospital bridging strategy. There is hardly any Advocacy to the ministries of health and education can be
stress for establishing a system for case detection and effective done for increasing awareness using a mass communication
referral of children identified with cataract. approach. Various NGOs, local community and health workers
can be involved in raising awareness on childhood cataract. The
There is lack of effective linkage of the centres with general awareness approaches could be through posters, radio, TV, cinema
ophthalmologists and other organisations providing primary halls, village fairs etc. These awareness materials can be designed
health/eye care. keeping in mind the knowledge, attitude and behavior of the
community for childhood blindness.

The quality of surgery performed is generally good but many Orientation sessions and CMEs for general ophthalmologists,
private sector hospitals emphasize surgical interventions rather general practitioners, paramedics and health workers can enhance
than on providing comprehensive care. In a study by GVS Murthy coverage and maximize the referral for childhood cataract.
et al10 on the status pediatric eye care in India; it was observed
that available facilities in India afforded a training opportunity to Detection and referral of child with cataract
ophthalmologists, but rarely to an entire pediatric team. A quarter
of the advanced hospitals did not possess a pediatric specialty The need of the hour is to establish an effective two-way referral
trained or oriented ophthalmologist, while 13.3% actually had system.
the benefit of a fully trained team.
This is the single most important factor for the successful
Available health communication materials are mostly focussed management of cataract in children. A variety of primary
on causes of blindness in adults leading to poor awareness in the health care workers can be trained to detect and refer any child
community about childhood blindness. with cataract. In India there are many organisations providing
community based rehabilitation (CBR) services. The existing
Health seeking behaviour – Sometimes unqualified practitioners curricula of training programmes of the field workers from CBR
and few traditional healers are the first person to be consulted. programmes can be strengthened to enhance their skill to detect
This leads to a delay in seeking treatment. and refer any blind child. The health workers from slum and
community development projects can also be involved in the
Another factor in the delay in seeking treatment for a child with process.
cataract is due to the fact that the primary health workers such
as Anganwadi or ASHA (Accredited Social Health Activist) Primary health workers such as Auxiliary Nurse Midwives
workers are not adequately trained to detect childhood cataract. (ANMs), Anganwadi and ASHA (Accredited Social Health

32 DOS Times - Vol. 16, No. 3, September 2010

willing to sponsor the expenses incurred on treating a blind child.
These local community donors can be mobilized for generating
resources for treatment of poor children with cataract. Similarly
many parents can afford partial or full cost of the treatment;
therefore a tiered pricing system (Sliding Scale fees) can help in
long term sustainability of the programme. These donors can be
felicitated in a ceremony to increase the potential donor base and
also to increase the awareness about childhood blindness.

Good counseling of the parents at the time of diagnosis, before
surgery and at the time of discharge from the hospital is mandatory
for restoring sight in children with cataract.

Follow-up of children after surgery

Figure 4: Low vision assessment following High incidence of complications after cataract surgery in
cataract surgery children12,13,14,15,16, such as PCO, amblyopia, changing refraction
and aphakic glaucoma, makes it mandatory to do regular follow
for a longer period of time. Follow-up services should also include
provision of low vision services, rehabilitation as well as inclusive
education services.

Activists) workers may be effective in identifying and referring Detailed low vision assessment is a must for all operated children
a child with cataract. In rural areas, most of the home deliveries and can be integrated with the refraction services. While basic
are conducted by the traditional birth attendants (TBAs), they low vision services can be provided at the secondary level centres,
can be trained to detect and refer congenital cataract. Screening advanced low vision services should best be provided at the
camps for children in the community can be organised with dual tertiary level.
purpose of raising awareness and detecting cataract in children.
Counselling of the family members at all stages from the time of
Childhood cataract is an important cause of blindness and severe diagnosis to the time of discharge is essential to ensure that the
visual impairment in significant number of children in the schools parents/family members understand the importance of follow
for blind in this region11. These children can be provided surgical up services. Detailed written information can be provided to the
treatment and optical correction. parents about the date of visit, contact person in the community
and hospital, warning symptoms/signs etc.
Getting the child to hospital
Some of barriers related to follow up such as distance and cost
Poor accessibility to the tertiary level centers for treatment of of travel can partially be overcome by providing follow-up
childhood cataract, particularly for those children living in services at the secondary level centres in the monthly paediatric
remote and rural areas, is a significant barrier. In the screening ophthalmology clinics. Some of the secondary level centres have
camps, children identified having cataract can be transported experienced ophthalmologists and ophthalmic paramedics and
on the same day to the tertiary level centers along with the adult the children operated can be given follow-up services at the
cataract patients. secondary level itself.

The secondary level centers in some places usually conduct Primary health workers and CBR workers have to be involved in
regular pediatric ophthalmology clinics visited by pediatric the process to motivate the parents for follow up of their operated
ophthalmologists. The children identified having cataract can children. Itinerant teachers can help in educational rehabilitation
be referred to these clinics, where they can be examined and of these children.
transported to the tertiary centers.
Networking
Also, some of the secondary level centers usually have regular
transport connectivity with the tertiary centers. The children The infrastructure and human resources in tertiary facilities for
identified with cataract can be referred to nearby secondary child eye health is usually underutilised due to low clinical load. On
centers on designated days for transportation to tertiary centers. the other hand, there are many blind children in the community
Local NGOs and individuals can also be mobilized for sponsoring due to treatable conditions such as childhood cataract. Networking
transport for a child with cataract. with various organisations may play a strong role in bridging this
gap and increased uptake of services in these facilities. Networking
Surgery of child with cataract can also be done with organisations providing special services such
as management of other disabilities, rehabilitation and inclusive
Most of the tertiary level child eye care centers in India have education.
well trained team of pediatric ophthalmologists, optometrists,
orthoptists and anesthetist along with good infrastructure. But, Networking can happen at all levels
cost of the surgery and follow up is a big barrier particularly in
poor people. In India, there are many people in the community • Primary level – Primary health workers (ANMs, Anganwadi
workers, ASHA workers, Itinerant teachers, CBR workers,
Traditional birth attendants)

www.dosonline.org 33

• Secondary & Tertiary level - General ophthalmologists, Eye 6. Rahi JS, Sripathi S, Gilbert CE, Foster A. Childhood blindness in
care facilities without paediatric eye care services, General India: causes in 1318 blind school students in nine states. Eye 1995;
practitioners, Paediatricians, Obstetricians, Organisations 9:545-50
providing rehabilitation, and inclusive education services.
7. Bhattacharjee H, Das K, Borah RR, Guha K, Gogate P, Purukayastha
• Advocacy at different forums for resource mobilization. S, Gilbert C. Causes of childhood blindness in the north-eastern
states of Indian. Indian J Ophthalmol. 2008 Nov-Dec; 56(6):495-9.
• Donors local and international for supporting treatment for
a child with cataract. 8. J.S. Titiyal, N Pal, G V S Murthy, S K Gupta, R Tandon, R B Vajpayee
and C E Gilbert. Causes and temporal trends of blindness and severe
Since the paediatric ophthalmology services require both vertical visual impairment in children in schools for the blind in North India.
and horizontal linkages for increased uptake of services, it British Journal of Ophthalmology 2003;87:941-945
requires a co-ordinating person who can work with the pediatric
ophthalmologist and other member of the team as well as with 9. Dorairaj SK, Bandrakalli P, Shetty C, R V, Misquith D, Ritch R.
the community and other service providers so that comprehensive Childhood blindness in a rural population of southern India:
services to children with cataract can be provided. prevalence and aetiology. Ophthalmic Epidemiol. 2008 May-
Jun;15(3):176-82.
Various studies17,18,19 have been done to understand the barriers
for accessing eye care services in children with cataract and 10. Murthy G, John N, Gupta SK, Vashist P, Rao GV. Status of pediatric
strategies have been recommended to reduce blindness due to eye care in India. Indian J Ophthalmol. 2008 Nov-Dec; 56(6):481-8
childhood cataract. Future research on the effectiveness of various
interventions in reducing childhood blindness due to cataract can 11. J S Titiyal, N Pal, G V S Murthy, S K Gupta, R Tandon, R B Vajpayee
help in modifying the strategies in this part of world. and C E Gilbert. Causes and temporal trends of blindness and severe
visual impairment in children in schools for the blind in North India.
In conclusion, the key challenges in restoring sight to children British Journal of Ophthalmology 2003;87:941-945
with cataract can be overcome by adopting a comprehensive
approach which involves various stakeholders and the community. 12. Keech RV, Tongue AC, Scott WE. Complications after surgery for
Multidisciplinary involvement is the key to provide all services congenital and infantile cataracts. Am J Ophthalmol. 1989 Aug
along with the support of parents and family members. 15;108(2):136-41.

References 13. Michaelides M, Bunce C, Adams GG. Glaucoma following congenital
cataract surgery--the role of early surgery and posterior capsulotomy.
1. World Health Organization. Preventing blindness in children: report BMC Ophthalmol. 2007 Sep 11;7:13.
of WHO/IAPB scientific meeting. Programme for the Prevention of
Blindness and Deafness, and International Agency for Prevention 14. Kirwan C, Lanigan B, O’Keefe M Glaucoma in aphakic and
of Blindness. Geneva: WHO, 2000 pseudophakic eyes following surgery for congenital cataract in the
first year of life. Acta Ophthalmol. 2010 Feb;88(1):53-9.
2. Gilbert CE et al. Prevalence of blindness and visual impairment in
children—a review of available data. Ophthalmic Epidemiology, 15. Pavlović S. Cataract surgery in children . Med Pregl. 2000 May-
1999, 6: 73–81. Jun;53(5-6):257-61

3. World Health Organization. Global initiative for the elimination of 16. Long V, Chen S, Hatt S. Surgical interventions for bilateral congenital
avoidable blindness. Programme for the Prevention of Blindness cataract. Cochrane Database Syst Rev. 2006 Jul 19; 3:CD003171
and Deafness. Geneva: WHO, 1997 (WHO/PBL/97.61).
17. Bowman RJ. How should blindness in children be managed? Eye
4. Global Initiative for the Elimination of Avoidable Blindness: action (Lond). 2005 Oct;19(10):1037-43.
plan 2006-2011. World Health Organization 2007 http://www.who.
int/blindness/Vision2020_report.pdf 18. Mwende J, Bronsard A, Mosha M, Bowman R, Geneau R, Courtright
P. Delay in presentation to hospital for surgery for congenital
5. Gilbert C, Foster A. Childhood blindness in the context of VISION and developmental cataract in Tanzania. Br J Ophthalmol. 2005
2020 - The Right to Sight. Bull World Health Organ. 2001; 79(3):227- Nov;89(11):1478-82
32.
9. Eriksen JR, Bronsard A, Mosha M, Carmichael D, Hall A, Courtright
P Predictors of poor follow-up in children that had cataract surgery.
Ophthalmic Epidemiol. 2006 Aug;13(4):237-43.

First Author
Subodh Kumar Sinha MS, MSc (CEH)

34 DOS Times - Vol. 16, No. 3, September 2010

Re-operations for Horizontal Muscles in Strabismus Squint

1Virender Sachdeva MS, DNB, 2Ramesh Kekunnaya FRCS, 2Amit Gupta MS, DNB,
1Vaibhev Mittal DOMS, 3B. Venkateshwar Rao MD

Primary surgery for a strabismus patient is fascinating and However, this article highlights the issues involved in the planning
gratifying if it is met with a good post-operative ocular and execution of re-operations for horizontal strabismus.
alignment. With a careful and meticulous planning, it is possible
to achieve desirable results in 85- 95% of the patients with simple All of these conditions necessitate a second surgery if these are
strabismus with adjustable and non-adjustable suture technique1,2. associated with a significant double vision, cosmetic blemish, and
In addition, with the better understanding of the pathophysiology abnormal head posture.
of complex problems like myopic strabismus fixus, thyroid
ophthalmopathy, congential fibrosis, etc, good success has been Pre-operative Evaluation
described in the hands of experienced surgeons3,4.
A detailed history taking and a meticulous evaluation should
However, there are instances when the surgery does not give be carried out. History should help determine the details of
desired post-operative results and rather may produce significant pre-operative ocular deviation, details of the primary surgical
overcorrection, under correction, significant double vision and/ procedure especially the surgical dosages if available. However,
or cosmetic blemish. Such an undesirable outcome may require complete details are only seldom available e.g. if the first surgery
a further intervention in the form of prismatic glasses and/ was done by the same surgeon and records are available. In most
or second surgical procedure. In addition, there may be some of the times, no details of the previous surgery may be available. In
indications where the surgeon may plan a stepwise approach to the such cases, the amount of information available is limited by the
management of a complex strabismus case thereby necessitating recall bias of the patients and/or parents. Previous photographs
a re-surgery on the previously operated/ un-operated muscles of the patient may help determine the nature of primary ocular
(naïve muscles) depending upon the situation. deviation and a comparison with the ocular deviation will let us
know whether we are dealing with residual/ consecutive ocular
There are no specific nomograms for re-operations on previously deviation. In addition, we should at least try and determine details
operated muscles as compared to surgery on naïve muscles. of previous surgery (whether unilateral or bilateral, muscle groups
Thus, re-operations for strabismus necessitate a meticulous pre- operated) so as to possible determine which muscles may have
operative examination and planning, determination of the intra- been operated.
operative findings and possible use of special surgical techniques.
A careful and meticulous examination should concentrate on
Indications for Re-operations in Strabismus the presence of conjunctival scars to determine which of the
previous muscles may have been operated (Figure 1) even when
Basic indications for re-operations can be sub classified as: the records of previous surgery are not available. It is usually
possible to determine the presence of conjunctival scars by a
• Residual Strabismus : e.g. Residual Exotropia/ Esotropia careful slit lamp examination and the patient can be made to look
out towards either gaze.
• Consecutive Strabismus: e.g. Exotropia following Esotropia
In addition, examination should concentrate on:
• Missed Deviation/ New consecutive Deviation e.g. Missed
Dissociated Vertical Deviation/ Superior Oblique (SO) palsy • Comprehensive Squint Evaluation
following SO Tenectomy in Brown’s Syndrome.
• Measurement of Ocular Deviation (for Distance and Near)
• Lost / Slipped muscle i.e. when the extra-ocular muscle
has been detached completely from globe allowing it to • Incomitance of Deviation, if Any.
retract posteriorly towards the apex of orbit (lost muscle)
or the muscle gets detached from the original or intended
insertion but remains attached posteriorly within the muscle
sheath (slipped muscle). Slipped/ Lost muscle are a cause
of immediate consecutive incomitant strabismus following
ocular surgery and a detailed discussion of the same is beyond
the scope of this article, though some relevant points to
planning may be described here.

1. Nimmagada Prasad Children’s Eye Care Centre, Figure 1: Showing the presence of the conjunctival scar
L.V. Prasad Eye Institute, (Bold Arrow) on anterior segment evaluation

GMRV Campus,Visakahapatnam. 37
2. Jasti V Ramanamma Children’s Eye Care Centre,

L.V. Prasad Eye Institute,
Kallam Anji Reddy Campus, Hyderabad.
3. Shreya Eye Care Centre, Hyderabad.

www.dosonline.org

Figure 2: Presence of an extra-ocular motility abnormality e.g. adduction lag in right eye
(arrow head) is suggestive of a muscle slippage or over-recession of the medial rectus muscle

• Extra-ocular Motility (Underaction of any Muscle e.g. Timing for Re-operation
Adduction Lag in Consecutive Exotropia)
In most of the cases re-operation should be done after a gap of 2 to
Ocular deviation should be measured very carefully as: 3 months after the primary surgery as by this time the maximum
effect of the primary surgery is achieved. However, in case of a
• Intra-operative decisions may need to be changed according suspected lost muscle the second surgery should be done as early
to the ocular deviation. as possible.

• This may be the last chance to undo the previous attempt at Planning re-surgery
achieving ocular alignment.
Various issues that arise in the planning for the re-operation in a
• There may be a significant emotional stress in the mind of patient with residual/ consecutive strabismus are:
the patient.
• Determining Which Muscles have been previously operated?
Presence of an extra-ocular motility abnormality e.g. an adduction
lag in a patient with consecutive exotropia is suggestive of an over- • Determining what is the expected position of the Muscles?
recession of the medial rectus muscle and/ or muscle slippage
(Figure 2). • To operate on Naïve Muscle vs Previously Operated Muscles?

Presence of such a pre-operative finding necessitates a careful • Do we have any Guidelines/ Nomograms?
examination at the time of surgery for the presence of a slippage
of the muscle, stretched muscle scar, etc. If confirmed, such a case Determining the expected position of the Extra-ocular muscles:
should be operated using an advancement of the involved muscle The first issue has been detailed already under the heading
with or without resection in order to strengthen the muscle. of pre-operative evaluation. However, it may be very difficult
According to some studies for patients with consecutive esotropia, to determine exactly the position of the previously operated
authors have suggested in case of slightest suspicion of a muscle extra-ocular muscles. Some of the clinical observations and
slippage even though it cannot be confirmed intra-operatively, it investigations can provide clues to the possible position of the
is desirable to include some kind of strengthening procedure for extra-ocular muscles.
the involved muscles.

38 DOS Times - Vol. 16, No. 3, September 2010

LENGTH TENSION CURVE

Figure 3: CT scan orbits of a patient with slipped medial Muscle Slack
rectus muscle following pterygium surgery showing the medial
Figure 4: Starling’s law stating that the result of the Muscle
rectus muscle within the muscle sheath on the right side slackening remains linear and thus predictable over a range

Clinical Clues: If reliable surgical details are available, and then if coefficient of variation for USG data were 2.02% and 3.18% for
there is no gross underaction of the muscle the extra-ocular muscle the MR muscle, and 7.33% and 11.77% for the LR muscle, in the
can be expected to be in the normal position. On the contrary, surgical and untreated groups, respectively suggesting that the
under action of the previously operated muscles may suggest a variability of the USG technique can be fairly high especially in
muscle slippage or over recessed muscle. E.g. In a patients who the re-operated cases.
had undergone Bilateral Medial Rectus Recession for Congenital
Esotropia, and has an adduction lag in one or both eyes may have In another study by Dai et al6, they compared 50 MHz UBM
a muscle slippage. and intra-operative measurements for the insertion of the rectus
muscles from the limbus. They found that the agreement between
Investigations to determine position of Extra-ocular muscles: the UBM and intraoperative measurements was very good to
Researchers have tried using various modalities such as USG excellent, with more than 80% of the readings being within 1mm.
B scan5, UBM6, CT scan orbits7, MRI8 and dynamic/cine MRI9 In addition, in the remaining cases also difference in readings
to determine the position of the extra-ocular muscles post- between the 2 modalities was less than 2mm, suggesting that
operatively; however the accuracy of the technique remains fairly variability remains less than 2mm. The maximum EOM insertion
poor even in routine cases. Imaging techniques such as Computed distance from limbus measured by 50-MHz UBM was 12mm for
Tomography (CT) scans and high-resolution magnetic resonance the MR and 14mm for the LR. Their study suggests a utility of
imaging (MRI), can demonstrate the origin and course of the extra the UBM technique for predicting the position of the extra-ocular
ocular muscles with sufficient detail. MRI is generally superior muscles, however, the range of the techniques suggests that it
to CT scans in delineating soft tissues. Indeed, various parts may not be possible to predict position of lateral rectus muscles
of the connective tissue of the extra ocular muscles can be well following fairly large recessions.
evaluated by MRI because of the sharp contrast between hyper
intense orbital fat and hypo-intense connective structures. Cine The above discussion suggests a limited efficacy of various
MRI, which is performed in different gaze positions to produce techniques in predicting the position of the extra-ocular muscles,
a video recording of ocular movements, has also been used to however, USG B scan and UBM in expert hands may help predict
analyze restrictive motility disorders. Although the use of the CT the position of the extra-ocular muscles. Thus, in most cases
scan orbits can give a reliable idea of the expected position of the surgeons have to decide the position of extra-ocular muscle
slipped or lost muscle (Figure 3), but because of the varying arc of intra-operatively,
contact and the isointensity of tendon and scleral tissue, an exact
determination of the extra ocular muscle insertion is not possible Operating on the previously operated muscles vs Operating
with the current resolution of CT and MRI. on the Naïve

Tamburrelli et al5 have described use of longitudinal USG B scan The decision to operate on which group of muscles depends on:
for the identification of the muscle insertion from the limbus using
iris root as a landmark for both un-operated and operated muscles. • The amount of the ocular deviation
They compared this with the measurement of the muscle position
intra-operatively for Medial Rectus (MR) and Lateral Rectus (LR) • The position of the extra-ocular muscles determined either
muscles respectively. In their study relative error of measurement by records/ investigations/ intra-operatively
was 6.15% ± 8.14% (mean ± SD) and 3.66% ± 12.83% for the MR
muscle, and 12.21% ± 10.66% and 7.69% ± 7.83% for the LR muscle • Presence of an underaction of the previously operated muscle.
in the surgical and untreated groups, respectively. In addition, the
Position of the extra-ocular muscles may be ascertained by
previous records/ investigations or/ and confirmed intra-

www.dosonline.org 39

Previous details unknown, Exploration Previous details unknown,
Adduction/Abduction Lag

Optimal Suboptimal Present, Absent
Surgery Surgery Exploration

Surgery on Supplemental Re-Surgery Advancement Advancement Other
previously Surgery on on previously alone + muscle
un-operated previously surgery
un-operated operated Resection
muscle muscle muscle +/-

Further
surgery on
other muscle

Preferable

Figure 5: Planning for a patient with residual Squint when Figure 6: Planning for reoperation in
details of previous surgery are not available a patient with consecutive Squint when details of

previous surgery are not available

operatively. If the amount of the previous surgery is inadequate advancement should be planned wherever under-action of a
then the muscles can be considered for re-recession, however, if muscle which is confirmed secondary to a slipped/ over-recessed
previously an adequate amount of the recession has been done, muscle. Advancement of a horizontal rectus by 1mm muscle gives
then it may be wise to operate on the naïve muscles. an expected 3 PD correction of the ocular deviation.

For example, in a patient with 50 PD Exotropia where previously In addition, advancement of a rectus muscle can also be
a Bilateral Lateral Rectus Recession (9mm) has been done, and a combined with resection of the muscle in order to achieve further
residual Exotropia of about 25 prism diopters, it is better to operate correction of the squint. However, according to some authorities,
on the Medial rectus muscles. However, in the same example, if advancement of the slipped muscle should always be combined
only about 3-4 mm recession of Lateral rectus is confirmed intra- with a small amount of the resection.
operatively a further re-recession may be equally effective.
In general it can be said,
Although there are no standard nomograms for the Re-operations,
re-recessions tend to follow the starling’s law (Figure 4). Hence, • Advancement alone can be planned if advancement to Limbus
the results tend to remain physiological and predictable as long corrects the deviation .e.g. 5 mm of MR advancement to
as the final position of the muscle remains in the range, however, limbus in one eye for about 15 prism diopters consecutive
if we tend to do over-recess them, unpredictable outcomes may Exotropia.
be achieved.
• Advancement + Resection: If Lax muscle is present / If
As a corollary, in case of a LR re- recession / MR re-recession, if muscle advancement alone is inadequate. E.g. for about
the final desired position of the extra-ocular muscle is within 9.5 25 prism diopters of Consecutive Exotropia a 5.5 mm MR
to 10 mm of the original insertion i.e. about 17 from the limbus advancement to limbus may be combined with 3.0 to 3.5 mm
for Lateral Rectus and 11.5mm form limbus for Medial Rectus, of MR resection.
a re-recession can be expected to give from predictable results.
Hence, a final decision regarding which groups of muscles have to
Therefore, intra-operative muscle position should be carefully be operated depends much on the amount of the ocular deviation
determined from the limbus and/or the original insertion and and the intra-operative findings. Therefore, operative plan should
an estimate should be made of the final position of the extra- include exploration of both eyes to check the position of the
ocular muscles with the intended amount of the re-recession. extra-ocular muscles and signs of possible muscle slippage and/or
For example, in a patient with a residual esotropia with previous stretched scars. Even in a case where the previous surgical details
MR recession, if on intra-operative examination Medial Rectus are not available using the above guidelines and intra-operative
is found bilaterally at 9.0mm from the limbus, then further MR findings at time of surgery, a decision can be taken regarding
recession is feasible by 2.5 mm in each eye which can correct about operating on which group of muscles (Figure 5 and Figure 6).
15 PD of residual esotropia. However, if the muscles are about 10.5
to 11.5 mm form the limbus, re-recession of the operated muscle Operative procedure/ technique: The general procedure remains
may not be helpful for majority of cases and it may be better to the same as in case of a Primary procedure, however, following
operate on the un-operated eye/ muscles. deviations may be observed:

Advancement of the Muscle: Advancement of a rectus muscle is a • Since an exploration of the muscles, followed by unilateral /
strengthening procedure which gives predictable results. Muscle bilateral procedure may be planned, it is desirable to perform
the surgery under general anesthesia irrespective of the age
of the patient.

40 DOS Times - Vol. 16, No. 3, September 2010

• To measure the position of the extra-ocular muscles, it is In another unpublished data from our institute, in 20 patients with

desirable to use a Scott’s Curved calipers rather than using consecutive Exotropia following Esotropia surgery details of the

Castroviejo calipers as it is more accurate. first surgery were available in only 4 patients.

• It may be preferable to use an adjustable suture technique A careful examination revealed the presence of an adduction lag in
rather than conventional recessions to improve the ocular the 14/20 (75%) patients. A slipped muscle was confirmed intra-
alignment and reduce the risk of post-operative diplopia. operatively in 11 of these cases. A medial rectus advancement
with/ without resection was performed in all 14 of these cases in
• In case of re-operations for a lost muscle, it is helpful to use a Lateral Rectus recession was performed. 1 patient. LR recession
microscope or a binocular loupe with a good magnification + MR resection was performed in 5 patients. Mean preoperative
to help identify the muscle. However, further discussion of a exodeviation (PD = Prism Diopter) was 43.62 SD ± 10.68PD and
case of lost muscle is beyond the scope of the present article. 46.58 SD ± 12.48PD at distance and near respectively. Surgical
techniques employed resulted in a successful postoperative result
Outcomes: In general good outcomes can be achieved in most (alignment within 8- 10 PD of orthophoria) in 18 (90%) of the
cases if a meticulous planning and surgical procedure can be patients. However, surgical plan had to be changed according to
carried out even when details of the previous surgery are not intra-operative findings in 11 patients (55%).
available.
Thus, good outcomes are achievable in patients with consecutive
Residual Recurrent Deviations: In general good outcomes can deviations if proper attention is paid to ocular details.
be achieved for residual or recurrent strabismus with either
re-recession vs. resection of naïve muscles. Both can be equally Patient Counseling: Good patient counseling is a key to planning
effective if properly planned. In a study by Chun Ki et al,8 they in patients undergoing re-operations. Most of these patients
described results of the 23 patients who underwent re-recession may have a significant amount of diplopia and emotional turmoil
of the previously recessed lateral rectus vs. resection of the medial following a previously unsuccessful procedure. In case they have
rectus muscles for recurrent exotropia. Success rates at the last already undergone surgery in one eye alone, they may be reluctant
follow-up after the second operation were 81.9% in re-recession to undergo surgery in the other eye especially if to be planned is
group and 83.3% in medial rectus resection group, showing the better seeing eye. In such patients, it is imperative to involve
no clinical or statistical difference between the two groups. In them in the decision taking and explain them the situation and
addition, in the re-recession group, no significant under action the likely procedure. They should be clearly explained about the
of the either lateral rectus muscle was noted. need for the bilateral exploration followed by surgery in one/
both eyes and possible assessment should be done for suitability
In another study by Yazdian and Ghiassi,9 they found that in for the adjustable suture squint surgery. Pre-operative and post-
recurrent exotropia patients, average 2.0‐4.0 mm bilateral lateral operative photographs of patients re-operated for squint may help
rectus muscles re‐recession was performed to less than 17.0 in achieving confidence in them.
mm from the limbus and the surgery was successful in 100 % of
patients in their series. Thus, it suggests if appropriately planned Thus, to conclude re-operations for strabismus is a challenging
re-recessions can be equally effective as resection of the naïve situation for each strabismologist. One should take a detailed
muscles, provided caution is exercised regarding exceeding the history and perform a meticulous pre-operative examination
physiological limits. before deciding to operate on such patients. Proper planning
may require the aid of the imaging and intra-operative findings.
Consecutive Deviations: Although various surgical approaches Although no clear nomograms exist, one can use the existing
have been described for patients with Consecutive Exotropia. guidelines for the primary surgery to plan for operating on the
Outcomes for patients with consecutive Strabismus however, previously operated muscles Vs. operating on new muscles.
tend to depend upon an under action of the muscles is present However, with proper planning good outcomes may be achievable
or not and whether or not an advancement procedure was the in most cases.
done for same.
References
‘Cooper’s dictum’10 describes that surgeons should assess patients
with consecutive Exotropia as though there had been no previous 1. Bishop F, Doran RM. Adjustable and non-adjustable strabismus
surgery and try to operate on the previously unoperated muscles surgery: a retrospective case-matched study. Strabismus. 2004
rather than “undo what was done” at the first operation. This Mar;12(1):3-11.
usually gives good results in cases with consecutive deviations but
no under action of operated muscles. In a study by Patel et al, they 2. Mohan K, Ram J, Sharma A. Comparison between adjustable
described good outcomes with bilateral Lateral Rectus recession and non-adjustable hang-back muscle recession for concomitant
in all patients with consecutive exotropia. exotropia. Indian J Ophthalmol. 1998 Mar;46(1):21-4.

However, in series by Donaldson et al11 and Biedner et al12 they 3. Kraus DJ, Bullock JD. Treatment of thyroid ocular myopathy with
have described good outcomes were achieved only in the cases who adjustable and nonadjustable suture strabismus surgery. Trans Am
underwent a planned and graded MR advancement procedure Ophthalmol Soc. 1993;91:67-79.
for the adduction lag in one or both eye. Kushner et al13 have
advocated that even a small adduction lag should be accompanied 4. Sturm V, Menke MN, Chaloupka K, Landau K. Surgical treatment
by Medial Rectus advancement/ Resection even if intraoperatively of myopic strabismus fixus: a graded approach. Graefes Arch Clin
there is no obvious muscle slippage. Exp Ophthalmol. 2008 Sep;246(9):1323-9.

5. Tamburrelli C, Salgarello T, Vaiano AS, et al. Ultrasound of the

www.dosonline.org 41

horizontal rectus muscle insertion sites: implications in preoperative rectus muscles re-recession and medial rectus muscles resection in
assessment of strabismus. Invest Ophthalmol Vis Sci 2003; 44:618- recurrent exotropia. Korean J Ophthalmol. 2008 Jun; 22(2):111-4.
22.
9. Yazdian Z, Ghiassi G. Re‐recession of the lateral rectus muscles in
6. Dai S, Kraft S P, Smith DR, Buncic JR. Ultrasound Biomicroscopy patients with recurrent exotropia. J AAPOS 2006; 10:164‐7.
in Strabismus Reoperations. J AAPOS 2006;10:202-205.
10. Cooper EL. The surgical management of secondary exotropia. Trans
7. Ozgen A, Alp MN, Ariyurek M, et al. Quantitative CT of the orbit Am Acad Ophthalmol Otolaryngol 1961; 65:595-608.
in Graves’ disease. Br J Radiol 1999; 72:757-62.
11. Patel AS, Simon JW, Lininger LL. Bilateral lateral rectus recession
8. Demer JL, Kerman BM. Comparison of standardized echography for consecutive exotropia. J AAPOS. 2000; 4:291-294.
with magnetic resonance imaging to measure extra ocular muscle
size. Am J Ophthalmol 1994; 118:351-61. 12. Mark J. Donaldson, Michael P. Forrest, and Glen A. Gole The surgical
management of consecutive exotropia. JAAPOS 2004; 3: 230-236
9. Cadera W, Viirre E, Karlik S. Cine magnetic resonance imaging of
ocular motility. J Pediatr Ophthalmol Strabismus 1992; 29:120-2. 13. Biedner B, Yassur Y, David R. Advancement and reinsertion of
one media rectus muscle as treatment for surgically overcorrected
10. Chun KI, Rah SH. The Comparison of outcomes between lateral esotropia. Binocul Vis Strabismus Q. 1991; 6:197-200.

First Author
Virender Sachdeva MS, DNB

42 DOS Times - Vol. 16, No. 3, September 2010

Superior Limbic Keratoconjunctivitis (SLK) Cornea

Ramendra Bakshi MS, FRCS, Mahipal Sachdev MD

Superior limbic keratoconjunctivitis (SLK) is a disease redness, foreign body sensation, burning and irritation of eyes.
characterised by inflammation of the upper palpebral and Usually the condition is bilateral, though the patient may be
superior bulbar conjunctiva, keratinisation of the superior limbus more symptomatic in one eye. History of thyroid dysfunction
and corneal and conjunctival filaments.1 is occasionally elicited upon questioning. The disease course is
prolonged with recurrences and remissions. Patient would have
Thygeson and Kimura described it as a chronic, localized, visited multiple practitioners earlier and would have used a myriad
filamentary conjunctivitis in 1963.2 Later, Theodore gave the name of eye drops before he or she meets you.
superior limbic keratoconjunctivitis (SLK).3 Common diseases
associated with SLK include keratoconjunctivitis-sicca(KCS), Slit lamp examination reveals marked velvety hyperemia and
hyperthyroidism, and hyperparathyroidism. These associations thickening of the superior bulbar conjunctiva. The conjunctiva
suggest an autoimmune etiology for SLK.1 is also loose, redundant and stains densely with Rose Bengal(RB)
stain. (Figure 1) There is associated inflammation and papillary
Etiopathogenesis reaction of the upper lid tarsal conjunctiva. Redundancy of
conjunctiva is well appreciated by pushing the upper lid on
Loose and dissolved Tenon tissue leads to the development of the superior globe in down-gaze. (Figure 2) Invariably, there is
superior conjunctivochalasis, which may result in a SLK-like punctate Rose Bengal staining around the limbus and superior
appearance by blink-related microtrauma. SLK is believed to be 1/3rd of the cornea. A large proportion of these patients also
present secondary to superior bulbar conjunctiva laxity, which present with filaments on the superior cornea and limbus.
induces inflammatory changes from mechanical soft tissue
microtrauma. Factors inducing conjunctiva laxity include thyroid Dry eye workup often shows decreased Schirmer’s and tear
eye disease, tight upper eyelids, and prominent globes.4-6 breakup time. Fluorescein Clearance Test shows delayed tear
clearance in these patients because of severe inflammation and
Several theories have been proposed to give a better understanding tear stasis. Thyroid function tests-Thyroid-stimulating hormone,
of the etiology of SLK. free thyroxine (T4), thyroid-stimulating immunoglobulin should
be asked for these patients.
Mechanical irritation
Treatment
The mechanical theory, suggests that the superior bulbar
conjunctiva, lax due to congenital or age-related factors, is Conservative management
affected by eye movement during blinking, resulting in chronic
inflammation.1,4-6 This constitutes the first step in managing these patients. Topical
corticosteroids, lubricants, topical antihistaminic and mast cell
Conjunctival redundancy stabilizers, topical cyclosporine all have a modulating effects on the
local immune environment. Large diameter bandage contact lens
Histologically squamous metaplasia, goblet cell loss, focal often helps alleviating the symptoms to a great extent. Occlusion of
inflammatory cells have beeen demonstrated in the diseased
conjunctival epithelium. These may be attributable to conjunctival
redundancy in and around the SLK lesion. This may result in
mechanical interaction between the palpebral and superior
bulbar conjunctiva during blinking. Alternatively, because
conjunctivochalasis occurs in patients with dry eye and thyroid
eye disease, it is possible that an initial event is increased friction
between the upper lid and conjunctiva, leading to both Rose Bengal
staining due to loss of mucin covering and conjunctivochalasis. It
remains unclear, however, whether the conjunctival redundancy
is the cause or the result of this mechanical interaction.7

Focal form of Conjunctivochalasis

It has also been proposed that SLK can be categorized as a type
of conjunctivochalasis of the superior bulbar conjunctiva rather
than as a separate disease entity.8-9

Clinical Features

The disease usually manifests in middle age. However any age- Figure 1: Marked velvety hyperemia and thickening
group may be affected. The patient complains of photophobia, of the superior bulbar conjunctiva. which stains densely

Centre For Sight with Rose Bengal stain
Safdarjung Enclave, New Delhi

www.dosonline.org 47

examination is essential in ruling out SLK. Superior bulbar
conjunctivochalasis and hyperemia should be looked for in all
patients with recurrent redness and photophobia. Treatment
ranges from conservative management in mild-moderate cases,
to surgical resection of the redundant conjunctiva in severe cases.

References

1. Nelson JD Superior limbic keratoconjunctivitis (SLK).Eye (Lond).
1989;3 ( Pt 2):180-9.

2. Thygeson P, Kimura SJ. Chronic Conjunctivitis. Trans Am Acad
Ophthalmol. 1963;67:494.

Figure 2: Redundancy of conjunctiva is well 3. Theodore FH. Further obser vations on superior limbic
appreciated by pushing the upper lid on the keratoconjunctivitis. Trans Am Acad Ophthalmol Otolaryngol
1967;71: 341–51.
superior globe in down-gaze
4. Ostler HB. Superior limbic keratoconjunctivitis. In: Smolin G, Thoft
RA, editors. The cornea. 3rd ed. Boston: Little,Brown and Company,
1987:296–298.

the superior puncta with plugs has also been reported and could 5. Cher I. Blink-related microtrauma: when the ocular surface harms
be combined with the bandage lens.10-12 itself. Clin Experiment Ophthalmol. Jun 2003;31(3):183-90

Surgical management 6. Cher I. Superior limbic keratoconjunctivitis: multifactorial
mechanical pathogenesis. Clin Exp Ophthalmol 2000;28:181–4.
Numerous treatment modalities that change the mechanical surface
of the conjunctiva, such as with 0.5% silver nitrate application, 7. Yokoi N, Komuro et al, New surgical treatment for superior limbic
conjunctival cauterization, cryotherapy and conjunctival keratoconjunctivitis and its association with conjunctivochalasis.
resection, have all been reported as being successful.11-15 Am J Ophthalmol. 2003 Mar;135(3):303-8.

Conjunctival resection technique involves making an arc-like 8. Meller D, Tseng SCG. Conjunctivochalasis: literature review and
conjunctival incision from the 2 to the 10 o’clock postion adjacent possible pathophysiology. Surv Ophthalmol 1998;43:225–232.
to the involved area. The conjunctiva is resected to form a crescent
using the arc-like incision as the base; the size of the resection 9. Tseng et al , New surgical approach for superior conjunctivochalasis.
is determined by conjunctival redundancy after removal of Cornea 2007;26:685–691Cornea. 2007 Jul;26(6):685-9
the subconjunctival connective tissue; and finally the crescent
conjunctival opening is closed with interrupted sutures or fibrin 10. S Watson et al, Treatment of superior limbic keratoconjunctivitis with
glue.7,13 a unilateral bandage contact lens. Br J Ophthalmol 2002;86:485-486

Reinforcement of conjunctival adhesion onto the sclera by 11. Udell IJ, Kenyon KR, Sawa M, et al. Treatment of superior limbic
amniotic membrane with either fibrin glue or sutures has also keratoconjunctivitis by thermocauterisation of the superior bulbar
been reported to be effective in alleviating symptoms and signs conjunctiva. Ophthalmology 1986;93:162–6.
in eyes with superior conjunctivochalasis. In this technique, the
redundant, thinned out conjunctiva is recessed up to the superior 12. Yang H-Y, Fujishima H, Toda I, et al. Lacrimal punctal occlusion
fornix. Thereafter, amniotic membrane, stromal side down is for the treatment of superior limbic keratoconjunctivitis. Am J
affixed with fibrin glue.9,14,15 Ophthalmol 1997;124:87.

Conclusion 13. Sun YC, Conjunctival resection combined with tenon layer
excision and the involvement of mast cells in superior limbic
Superior limbic keratoconjunctivitis is a commonly encountered keratoconjunctivitis. J Ophthalmol. 2008 Mar;145(3):445-452.
yet misinterpreted entity. A thorough history and clinical
14. Tseng al, Amniotic membrane transplantation with fibrin glue for
conjunctivochalasis.Am J Ophthalmol. 2007 Aug;144(2):311-3.

15. Gris O et al,Conjunctival Resection With and Without
Amniotic Membrane Graft for the Treatment of Superior Limbic
Keratoconjunctivitis. Cornea. 2010;29(9):1025-30.

First Author
Ramendra Bakshi MS, FRCS

48 DOS Times - Vol. 16, No. 3, September 2010

Paediatric Eye and Vision Screening Paediatric Ophthalmology

Neha Goel MS, DNB, Gauri Bhushan MBBS, Usha Kaul Raina MD, FRCOphth,
Meenakshi Thakar MD, FRCS(Ed), Basudeb Ghosh MD MNAMS

Paediatric eye examination includes screening by a paediatrician Examination of a child1,2
and a detailed eye examination by an ophthalmologist. WHO
guidelines for a disease that benefits from screening include • Assessment of vision – according to age
a health problem for which there is an accepted treatment, a
recognizable latent or early symptomatic stage, and a suitable test • Infants (Pre Verbal child) - Fixation pattern, Catford drum,
or examination. The aim of screening is to identify children who Forced Preferential looking test (Teller acuity cards, Cardiff
may have eye or visual abnormalities, or risk factors for developing acuity cards), Optokinetic Nystagmus (OKN), Pattern VEP
eye or vision problems, and refer them for a comprehensive
paediatric ophthalmic evaluation. • 1 – 2 years (Pre Verbal child) - Forced Preferential looking
test (Teller acuity cards, Cardiff acuity cards), Boeck candy
When to screen1 bead test, STYCAR graded ball test, Worth ivory ball test

1. A newborn's eyes must be examined for general eye health • 2 - 3 years (Verbal preliterate child) – Allen’s picture cards
and a red reflex test should be performed in the nursery. The (Figure 1a), Kay’s picture test, Sheridan’s miniature toy test,
baby with an abnormal red reflex (retinoblastoma, cataract, LEA symbols (Language skills sufficient to name pictures)
high refractive error, PHPV, Coats disease, fundal coloboma,
toxocariasis) requires urgent consultation. • 3 – 4 years (verbal preliterate child) - Tumbling E test (Figure
1b), Landolt’s C test, Sheridan – Gardener test, HOTV test
2. All infants should be screened by six months to one year of (Able to match letter optotypes)
age for ocular health.
• Age more than 6 years (literate child) – Snellen’s chart, ETDRS
3. Vision and alignment should be assessed in children between chart
3 and 3 1/2 years of age. It is essential that a formal testing of
visual acuity be performed by the age of 5 years. External examination

4. Further screening examinations should be done at routine • Look for signs of birth trauma /lid bruising etc
school checks or after the appearance of symptoms. Routine
comprehensive professional eye examination of the normal • Globe size / Palpebral fissure & lid abnormalities
asymptomatic child has no proven medical benefit.
• Cornea --approximate size, any edema/any opacity
How to screen (Table 1)2
• Iris -- color / any coloboma /Persistent Pupilary Membrane
(PPM)

Ocular History1,2 Ocular alignment and motility - Ocular alignment is assessed by
Parents’ observations are valuable. Questions that can be asked using the corneal light reflection (Hirschberg test), the binocular
include: red reflex (Brückner) test, or the cover test. In the inattentive or
• Does your child seem to see well? uncooperative patient, eye movements may be tested using the
• Does your child hold objects close to his or her face when oculocephalic rotations manoeuvre (doll’s head) or assessed by
spontaneous eye movements.
trying to focus?
• Do your child’s eyes appear straight or do they seem to cross Pupil examination

or drift or seem lazy? Red reflex/Binocular red reflex (Bruckner) test - In a darkened
• Do your child’s eyes appear unusual? room, the ophthalmoscope light is projected onto both eyes of
• Do your child’s eyelids droop or does eyelid tend to close? the child simultaneously from approximately 30 inches away
• Have your child’s eye(s) ever been injured? and look for the symmetry and quality of red reflex from each
Relevant family histories regarding eye disorders or preschool eye. To be considered normal, a red reflex should emanate from
or early childhood use of glasses in parents or siblings should be both eyes and be symmetric in character. Abnormalities include
explored. asymmetric reflexes when one reflex is duller or a different colour,
a white reflex, a partially or totally obscured reflex, or crescents
Paediatric Ophthalmology Services, present in the reflex (Figure 1).
Guru Nanak Eye Centre, Maulana Azad Medical College, New Delhi
Photoscreening - Using this technique, a photograph is produced
by a calibrated camera under prescribed lighting conditions,
which shows a red reflex in both pupils. A trained observer
can identify ocular abnormalities by recognizing characteristic
changes in the photographed pupillary reflex. When performed
properly, the technique is fast, efficient, reproducible, and highly

www.dosonline.org 53

Table 1: How to screen

Recommended age Method Indications for referral to an ophthalmologist
Absent, white, dull, opacity, or asymmetric
Newborn - 3 months Red reflex Structural abnormality
External inspection Irregular shape, unequal size, poor unequal reaction
Failure to fix and follow in a cooperative infant
Pupil examination Absent, white, dull, opacity, or asymmetric
Structural abnormality
3 – 6 months Fix and follow Irregular shape, unequal size, poor or unequal reaction
Failure to fix and follow
Red reflex
Failure to object equally to covering each eye
External inspection Asymmetric or displaced
Absent, white, dull, opacity, or asymmetric
Pupil examination Structural abnormality
Irregular shape, unequal size, poor or unequal reaction
6 to 12 months and until child is Fix and follow with 6/18 or worse, or 2 lines of difference between the eyes
able to cooperate each eye Asymmetric/ocular refixation movements
for verbal visual acuity
Alternate occlusion Absent, white, dull, opacity, or asymmetric
Structural abnormality
Corneal light reflection Irregular shape, unequal size, poor or unequal reaction
6/18 or worse, or 2 lines of difference between the eyes
Red reflex
6/18 or worse, or 2 lines of difference between the eyes
External inspection

Pupil examination

3 – 4 years Visual acuity (monocular)
Corneal light reflection/
cover- uncover

Red reflex

External inspection

Pupil examination

5 years Visual acuity (monocular)
All other tests and referral
indications are as in age 3
and age 4 years

Every 1 to 2 years after age 5 Visual acuity (monocular)
All other tests and referral
indications are as in age 3
and age 4 years

reliable. Photoscreening is not a substitute for accurate visual Diabetes Mellitus4
acuity measurement but can provide significant information
about the presence of sight threatening conditions, such as Factors that influence the onset of diabetic retinopathy (DR)
strabismus, refractive errors, media opacities (cataract), and retinal include duration of disease (risk of DR increases with time); age
abnormalities (retinoblastoma).3 (children younger than 10 years with type 1 diabetes mellitus
are at minimal risk of the development of significant ocular
Special situations complications), puberty (hormonal changes associated with
puberty exert an effect that is independent of age and duration
Screening for Retinopathy in the paediatric patient with Type 1 of disease).

54 DOS Times - Vol. 16, No. 3, September 2010

(a) (b)

Figure 1: (a) Allen’s picture cards (b)Tumbling E test.

Table 2 – When to screen for ROP The goal of an effective screening program must be to identify
the relatively few preterm infants who require treatment for ROP
Gestational Age at initial Age at from among the much larger number of at-risk infants while
Age at examination initial examination minimizing the number of stressful examinations required for
postmenstoral these sick infants
Birth (wk) chronologic
Who to screen - Infants with birth weight of less than 1500 g or
22 31 9 gestational age of 30 weeks or less, as well as selected infants with
23 31 8 birth weight between 1500 and 2000 g or gestational age greater
24 31 7 than 30 weeks with an unstable clinical course, including those
25 31 6 requiring cardiorespiratory support, who are believed by their
26 31 5 attending pediatrician or neonatologist to be at high risk, should
27 31 4 have retinal screening examinations performed.
28 32 4
29 33 4 When to screen -The initiation of acute-phase ROP screening
30 34 4 should be based on the infant’s age (Table 2). The onset of serious
31 35 4 ROP correlates better with postmenstoral age (gestational age at
32 36 4 birth plus chronologic age) than with postnatal age. That is, the
youngest infants at birth take the longest time to develop serious
The American Academy of Ophthalmology recommends annual ROP.
screening beginning 5 years after the onset of diabetes.
How to screen - Retinal examinations in preterm infants should
The American Diabetes Association recommends annual be performed by an ophthalmologist after pupillary dilation
screening beginning 3 to 5 years after diagnosis of diabetes once using binocular indirect ophthalmoscopy. The “International
the patient is 10 years or older. Classification of Retinopathy of Prematurity” should be used to
classify, diagram, and record these retinal findings at the time of
The American Academy of Paediatrics recommends an initial examination. Effort should be made to minimize the discomfort
examination 3 to 5 years after diagnosis if older than 9 years, with and systemic effect of this examination by pretreatment of the eyes
annual follow-up thereafter. with a topical anaesthetic agent, such as proparacaine, the use of
pacifiers, oral sucrose, etc.
Screening Examination of premature infants for Retinopathy of
Prematurity (ROP)5 One examination is sufficient only if it unequivocally shows the
retina to be fully vascularised in each eye. Conclusion of acute
screening examinations should be based on age and retinal
ophthalmoscopic findings:

www.dosonline.org 55

Table 3: Suggested frequency of ophthalmologic visits for children with Juvenile Rheumatoid Arthritis (JRA) without
known uveitis at diagnosis and during follow-up.

Type ANA Age at onset Duration of disease Risk Category Frequency of
(yrs) (yrs) eye examination (months)

Oligoarthritis or + <6 <4 High 3
polyarthritis + <6 >4 Moderate 6
+ <6 >7 Low 12
Systemic disease + >6 <4 Moderate 6
(fever, rash) + >6 >4 Low 12
- <6 <4 Moderate 6
- <6 >4 Low 12
- >6 NA Low 12
NA NA NA Low 12

(a) (b)

Figure 2: Abnormalities of the red reflex (a) Leucocoria
(b) Abnormal Bruckner (binocular red reflex) test

• Zone III retinal vascularization attained without previous chronic uveitis. Most children with uveitis have an oligoarticular
zone I or II ROP. If there is examiner doubt about the zone or onset.
if the postmenstrual age is less than 35 weeks, confirmatory
examinations may be warranted. Chronic uveitis may be detected at the time of initial diagnosis of
arthritis; however, if not present at onset, it most often presents
• Full retinal vascularization. during the next 4 to 7 years. The period of highest risk is within 4
years of onset of arthritis. Eye involvement precedes involvement
• Postmenstrual age of 45 weeks and no prethreshold disease of the joints in approximately 5% of cases. The activity of the
(defined as stage 3 ROP in zone II, any ROP in zone I) or uveal inflammation does not parallel that of the joint disease.
worse ROP is present. Antinuclear antibodies are present in 65% to 90% of children with
chronic uveitis and are a major risk factor for its development
• Regression of ROP. Care must be taken to be sure there is no
abnormal vascular tissue present capable of reactivation and The onset of ocular inflammation is insidious and asymptomatic
progression. in most young children. Because of the lack of symptoms or the
cognitive recognition by the child, the exact time of onset of ocular
Screening in patients with Juvenile Rheumatoid Arthritis (JRA)6 involvement is frequently difficult to determine. This observation
emphasizes the requirement for slit-lamp examination by an
The onset type is determined by the systemic features of the illness ophthalmologist at diagnosis of JRA and periodically thereafter
and the number of joints with arthritis at diagnosis. Oligoarticular (Table 3). Because a substantial number of patients may have the
JRA is defined by involvement of 4 or fewer joints; polyarticular eye disease before or shortly after their arthritis is diagnosed, they
JRA is defined by involvement of >4 joints (usually 10-20); and should have their initial eye examination within 1 month of the
systemic-onset JRA is defined by quotidian fever during the first 6 diagnosis of arthritis.
weeks of the illness, almost always associated with a characteristic
rash. Less than 1% of children with systemic-onset JRA develop

56 DOS Times - Vol. 16, No. 3, September 2010

Table 4: Referral Plan Early referral Routine referral
Immediate referral –
Doctor on call -- A & E • Congenital cataracts • Abnormal head position
• Acute red eye • Suspected congenital • Anophthalmos, microphthalmos/
• Suspected foreign body cornea
glaucoma microcornea
• Corneal ulcer • Ptosis covering pupil • Congenital nasolacrimal duct obstruction
• Orbital cellulitis • Aniridia • Ptosisnotcoveringpupil,lidhaemangiomas

• Leucocoria • Lid colobomas – unless -not covering pupil
cornea exposed • Down syndrome
• Ophthalmia neonatorum
• Birth trauma • Galactosemia • Allergic conjunctivitis/Vernal
• Strabismus - Keep in Keratoconjunctivitis (VKC)

mind age of patient and • Chalazion
duration of history
• Nystagmus
• Tearing/discharge
• Proptosis

Role of a paediatrician arthritis. American Academy of Pediatrics. Sections on Rheumatology
and Ophthalmology. Pediatrics 2006;117;1843-5. (http://aappolicy.
All paediatricians and other providers of health care to children aappublications.org/cgi/content/full/pediatrics;117/5/1843).
should be familiar with the eye examination guidelines mentioned
above. Children should have an assessment for eye problems First Author
in the newborn period (at birth, in the nursery) and then at all Neha Goel MS, DNB
subsequent routine health supervision visits (well baby clinic,
etc). Every effort should be made to ensure that eye examinations 57
are performed using appropriate testing conditions, instruments,
and techniques. All children who are found to have an ocular
abnormality or who fail vision screening should be referred to a
paediatric ophthalmologist or an eye care specialist appropriately
trained to treat paediatric patients (Table 4). Early detection and
prompt treatment of ocular disorders in children is important to
avoid lifelong permanent visual impairment.

References

1. Eye examination and vision screening in infants, children,
and young adults by pediatricians. American Academy of
Pediatrics Committee on Practice and Ambulatory Medicine and
Section on Ophthalmology, American Association of Certified
Orthoptists, American Association for Pediatric Ophthalmology and
Strabismus, and American Academy of Ophthalmology. Pediatrics
2003;111:902-7. (http://aappolicy.aappublications.org/cgi/content/
full/pediatrics;111/4/902)

2. American Academy of Ophthalmology Pediatric Ophthalmology/
Strabismus Panel. Preferred Practice Pattern® Guidelines. Paediatric
eye evaluations. San Francisco, CA: American Academy of
Ophthalmology; 2007. Available at: http://www.aao.org/ppp.

3. Ottar WI, Scott WE, Holgado SI. Photoscreening for amblyogenic
factors. J Pediatr Ophthalmol Strabismus 1995;32:289–95.

4. Screening for retinopathy in the pediatric patient with type 1
diabetes mellitus. American Academy of Pediatrics. Sections on
Endocrinology and Ophthalmology. Pediatrics 2005;116:270-
3. (http://aappolicy.aappublications.org/cgi/content/full/
pediatrics;116/1/270)

5. American Academy of Pediatrics, Section on Ophthalmology,
American Academy of Ophthalmology, and American Association
for Pediatric Ophthalmology and Strabismus. Screening examination
of premature infants for retinopathy of prematurity. Pediatrics.
2006;117:572-6.

6. Ophthalmologic examinations in children with juvenile rheumatoid

www.dosonline.org

Group Practice in Ophthalmology Miscellaneous

Vidushi Sharma MD, FRCS, Suresh K Pandey MS

In recent years, Group Practice has become a concept, that is like insurance companies, organizations for empanelment,
often talked about, and everyone seems to wax eloquent on how civic agencies, medical equipment manufacturing companies
good and useful Group Practice can be for all involved. And yet, etc. This would also protect them from unwanted elements like
there are very few examples of a really successful group practice, blackmailers, corrupt officials etc. who unfortunately make doctors
where the stakeholders are all happy and the association can last a soft target. This could theoretically become a win-win situation
for a long time. So, what is it about Group Practice that makes it for all – the doctors in the group as well as their patients.
an idea, “easier discussed than implemented”? Why is it that the
list of perceived advantages of Group Practice is so long, and yet On the other hand, there are definite advantages to Solo practice.
there are few models in practice, from which beginners can take Though it may seem less glamorous and more outdated to see a
inspiration and follow their example? Or is it that ophthalmologists single doctor managing everything in a small, unassuming set-
are simply not suited for the concept? And after all, why make the up, but it really suits those who like to make their own decisions
change from Solo to Group practice, when solo practices have and chart their own course. You can decide your own timings;
survived and done well for years? your own direction for future growth, work at your own pace
and the money you make is all yours. Your only arguments are
The reason why we need to discuss all this is because our society, with your spouse and there is no need to have endless discussions
medical science, the nature of practices and everything else about revenue sharing etc. And then, there are many examples of
around us is changing so fast, that we need to respond equally fast individual ophthalmologists, who have single-handedly earned
to these changes and evolve new methods of keeping up. While more name as well as money than even large institutions.
it was alright till even 2-3 decades ago to take things easy, and a
reasonable level of competence was enough for a doctor to survive The key therefore is to choose the right option for yourself. It is
and do well in society, with adequate financial remuneration unwarranted to have a debate over whether Group Practice is
and lot of respect; today the scenario has changed dramatically. better than Solo Practice or vice versa, but to choose what suits
It is still a matter of individual choice and personality to take you best. Whether for solo or for group, it is imperative to have
things easy or not, but we now live in a very demanding society, clear objectives and goals beforehand and chart your course
with constant pressure to do more, be more and give more and accordingly. At the same time it is equally important to be honest
there is ever increasing competition. Our role models are all to yourself as well as your colleagues. For example, it is perfectly
ophthalmologists, who strived hard and achieved tremendous legitimate for a beginner to join a group practice for few years,
financial success and acclaim; and to achieve even a fraction before starting a solo practice, to gain experience and earn some
of that today, needs a lot more hard work and varied skills to start-up money. But it would be best to be clear about this course
establish and run a successful ophthalmic practice. For doctors, and let the colleagues in the group know about your future plans.
the real need of the hour is to somehow become more efficient and At the same time, the group should also honestly make it clear to
achieve more (more technology, more expertise, more volumes, the new entrant about the kind of responsibilities and job profile.
more attractive workplace) with less (less time, less staff and less
money) and the need of the hour for the society is to contain the Pros and Cons of Group Practice
spirally rising costs of medical treatment. It would also be in the
interest of ophthalmologists and doctors in general to try and Let us also have a closer look at some of the perceived advantages
evolve new models to contain medical costs, before we are forced and disadvantages of Group Practice. For example, one of the
to do so by society and government. most often cited advantage of Group Practice is sharing the cost
of medical equipment, bringing down the start-up cost. Now,
Group Practice Vs Solo Practice a beginner Solo Ophthalmologist, basically starts with a phaco
set-up and expands along the way as the earnings increase. So,
Where does the concept of Group Practice stand amidst all this? he/she would need about 25-30 lakh rupees for a good operating
The advocates of Group Practice consider this as one of the best microscope, phaco machine, A-scan, slit lamp, OPD instruments
methods to contain costs and increase efficiency of doctors, etc. On the other hand, a group practice would usually be with
allowing them more personal time. Most certainly, it is obvious members taking interest in different sub-specialties, which would
that if a group of doctors can share the same equipment and staff need about 2-3 crore rupees, if the set-up for all sub-specialties
and expert managerial assistance, the costs would come down is included. If this is shared among say 5 people, it would give
dramatically and this arrangement would also allow doctors a cost of 40-50 lakhs per person. Of course, it is possible to
more flexibility in their daily work schedules. This would also have a group start only with phaco set-up, but it would be most
make the group of doctors more strong in society and give them impractical in a new set-up for all group members to focus only on
better negotiating power when dealing with diverse elements cataracts in a limited base of initial patients. While, there may be
many variations to the basic concept of group practice and these
Suvi Eye Hospital & Research Centre examples may not be universally true, but this applies to most
Kota, Rajasthan situations. Also, the idea of having more flexible schedules and
personal time generally isn’t true, for the amount of work increases

www.dosonline.org 59

as the size of practice increases and also because of heightened can be many variations on the basic theme of sharing expenses,
patient demands. However, the system of Group Practice certainly administrative duties and financial returns, based on the unique
allows for some leeway in situations like illness, personal functions requirements of your practice setting. For example, in a big city,
etc., without breaking the patient chain, unlike in a Solo Practice. it is possible to have independent OPD set-ups in different parts
of the city and share a common operating facility. In a smaller
In a nutshell, Group Practice is not so much about making quick city, it is possible to have some mobile equipments, which can
money with minimal investment, even while working less and be shared on a rotatory basis with someone being independently
having more free time, but is more about achieving a broader responsible for maintenance. The most important requirement
vision and being able to do better quality work with cutting edge for any arrangement to be successful is of course, HONESTY and
technology. The patients are also benefited as all sub-specialties trying to avoid any one up-man ship. But ophthalmology being
and cross-opinions are available under the same roof. The patient so competitive, one up-man ship can be avoided only if there are
care improves and the cost to the patient also comes down in some very rational and acceptable models for revenue sharing. It is a
situations, not to forget situations like the dreaded nucleus drop, good idea to have revenue sharing based on share in capital as well
which can be immediately taken care of. This kind of group also as individual productivity. It is extremely important to remember
attracts more patients, because it looks bigger and better and raises that perfect equality is a myth and there is no such thing as a 50-50
lesser doubts among patients. partnership. It is just like marriage where you must “keep your
eyes wide open before marriage and half shut afterwards”. Often,
Group Practice remains an elusive goal, which everyone wants to it is a rewarding exercise to stop comparing your deal with your
achieve, but is mostly out of reach. The most common reason for colleague’s deal and compare instead with what you would achieve
this failure is inability among the members to share a common if you went Solo. In practices, with members belonging to different
vision. And that is the reason why Group Practice will always be age groups, there must be some acceptance for change in opinions
a difficult to achieve utopian ideal, for it is impossible for any 2-3 that comes with age as well as changed training etc.
or 4 people to agree on everything for a long time. Differences
of opinion are bound to arise, egos are going to be ruffled, Conclusion
financial matters will become more and more touchy as the
revenues increase; and that is perfect recipe for divorce. So, are If we can learn to live with our small differences and inequalities
ophthalmologists not suited for this concept and should give it and enjoy variety, we must try to form groups with clear and
up? No, but make sure you find the right partners for your group. well-discussed goals. If not, there is absolutely nothing wrong in
Discuss your goals and priorities very clearly before associating going Solo and singing your own tune, for a group is worthwhile
rather than somehow roping in people to provide capital and then only if it can deliver a coordinated jugalbandi rather than an
realizing that everyone is moving in a different direction. Also, uncoordinated cacophony.
there doesn’t have to be a set pattern for Group Practice. There

First Author
Vidushi Sharma MD, FRCS

60 DOS Times - Vol. 16, No. 3, September 2010

Delhi Ophthalmological Society Fellowship for Partial
Financial Assistance to Attend Conferences

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

Conferences Points Awarded

International: Three fellowships per year (Two fellowships can be 1) Age of the Applicant Points
awarded at a time if committee feels that papers are very good)
a) < 35 years 10
• Maximum of Rs. 35,000/- per fellowship will be sanctioned
National: Three fellowships per year (Only for AIOS) b) 36 to 45 years 07

• Maximum of Rs. 10,000/- per fellowship will be sanctioned c) 45 years plus 05
Eligibility 2) Type of Presentation

• DOS Life Members (Delhi Members only) a) Instructor/ Co-instructor of Course 12

• 75 or More DCRS Points b) Free Paper (Oral) / Video 07

• Accepted paper for oral presentation, poster, video or instruction c) Poster 05
course. 3) Institutional Affiliation

Time since last DOS Fellowship a) Academic Institution 15
Preference will be given to member who has not attended conference in
last three years. However if no applicant is found suitable the fellowship b) Private Practitioner 20
money will be passed on to next year. Members who has availed DOS 4) DCRS Rating in the immediate previous year
fellowship once will not be eligible for next fellowship for a minimum
period of three years. a) 75-150 05
Authorship
b) > 150 08
The fellowship will be given only to presenting author. Presenting
author has to obtain certificate from all other co-authors that they are c) < 75 not eligible for fellowship
not attending the said conference or not applying for grant for the same Documents
conference. (Preference will be given to author where other authors are
not attending the same conference). If there is repeatability of same author • Proof for age. Date of Birth Certificate
group in that case preference will be given to new author or new group
of authors. Preference will also be given to presenter who is attending • Original / attested copy of letter of acceptance of paper for oral pre-
the conference for the first time. sentation / video / poster or instruction course.
Quality of Paper
• Details of announcement of the conference
The applicant has to submit abstract along with full text to the DOS
Fellowship Committee. The committee will review the paper for its • Details of both International & National Conferences attended in
scientific and academic standard. The paper should be certified by the previous three years.
head of the department / institution, that the work has been carried out
in the institution. In case of individual practitioner he or she should • Copy of letter from other national or international agency / agencies
mention the place of study and give undertaking that work is genuine. committing to bear partial cost of conference if any.
The fellowship committee while scrutinizing the paper may seek further
clarification from the applicant before satisfying itself about the quality • At least one original document should be provided, that is ticket,
and authenticity of the paper. Only Single best paper has to be submitted boarding pass or registration certificate along with attendance cer-
by the applicant for review (6 copies). Quality of the paper will carry tificate of the conference.
50% weightage while deciding the final points.
Poster and Video • Fellowship Money will be reimbursed only after submission of all
the required documents and verified by the committee.
The applicant will need to submit poster and video for review.
Credit to DOS • Undertaking from the applicant stating that above given information’s
are true.
The presenter will acknowledge DOS partial financial assistance in
the abstract book / proceedings. • If found guilty the candidate is liable to be barred for future fellow-
The author will present his or her paper in the immediate next DOS ships.
conference and it will be published in DJO/DOS Times.
Application should reach Secretary’s office and should be addressed
to President, DOS before 30th July, 31st October and 31st January
for International Conference and before 30th September for National
Conference. The committee will meet thrice in a year in the month of
August, November and February with in 2 weeks of last date of receipt
of applications. The committee will reply within four week of last date
of submission in yes/no to the applicant. No fellowship will be given
retrospectively, that means prior sanction of executive will be necessary.

Dr. Amit Khosla
Secretary
Delhi Ophthalmological Society
Room No. 2225, 2nd Floor, New Building,
Sir Ganga Ram Hospital, Rajinder Nagar
New Delhi - 110060
Ph : 011-65705229
Email : [email protected]

www.dosonline.org 63

Forthcoming Events: National

October 2010 December 2010

22-24 UTTARAKHAND 2-4 MYSORE
NZOS & Uttara Eyecon 2010 19th Annual Conference of Vitreo Retina Society -
(Combined Annual conference of North Zone India 2010
Ophthalmological Society and Uttarakhand State Organizing Secretary,
Ophthalmological Society) Retina Institute of Karnataka
Venue: Hotel Park Plaza, Mall Road, Mussorie, #122, 5th Main Road, (Next to Venlakh Hospital)
Uttarakhand Chamarajpet, Bangalore - 18
Organizing Secretary: Ph: +91-80-22410106 / 536 (Hospital)
Dr. B.K.Oli Fax: +91-80-26607811
57, Haridwar Road, Dehradun-248001 E-mail: [email protected]
Phone: 0-99971-22222, 0-94123-19035
Email: [email protected] 18-19 JAIPUR
Annual Conference of Strabismological Society of India
28-31 NEW DELHI Contact Person:
10th Annual Meeting of Uveitis Society of India Dr. Virendra Agarwal
Venue: Advanced Eye Centre, PGI Chandigarh 104, Shyam Anukampa, Opp. HDFC,
Contact Person & Address Ahinsa Circle, C-Scheme, JAIPUR
Dr. Vishali Gupta (M) 09829017147, 09414043006
email : [email protected] Website: www.strabismusindia.com
www : http://www.usi2010.in

November, 2010 February 2011

12-14 NEW DELHI 3-6 GUJARAT
20th Annual Conference of Glaucoma Society of India 69th AIOS Annual Conference
& 5th International Congress on Glaucoma Surgery Gujarat University Convention Centre, Ahemadabad
Venue: Le Meridien Hotel, Janpath, New Delhi & Conference Secretary,
India Habitat Centre, Lodhi Road, New Delhi Dr. Tejas D. Shah
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(M): 9810442537, Tel.: 91-11-4519910, 25513051, Fixed: +91 79 26303208, Fax: +91 79 26303308
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Conference Help Line: 96248 96248

27-28 NEW DELHI
Mid-term Conference
Delhi Ophthalmological Society April 2010
Venue: India Habitat Centre, Lodhi Road, New Delhi
Contact Person & Address 15-17 NEW DELHI
Dr. Amit Khosla, Secretary DOS Annual Conference
Room No. 2225, 2nd Floor, New Building, Delhi Ophthalmological Society
Sir Ganga Ram Hospital, Venue: Hotel Ashok, Chanakya Puri, New Delhi
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Ph.: 011-65705229, E-mail: [email protected] Dr. Amit Khosla, Secretary DOS
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Sir Ganga Ram Hospital,
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Ph.: 011-65705229, E-mail: [email protected],
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Forthcoming Events: International

October, 2010

6-9 GREECE
EVER 2010 Congress
Venue: Creta Maris, Creta, Greece
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EVER Office
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Fax +32 16 234 097
Email: [email protected]

16-19 CHICAGO, USA
American Academy of Ophthalmology

Venue: Chicago, IL, USA
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March, 2011

20-24 SYDNEY, AUSTRALIA
APAO

Venue: Sydney, Australia
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Sydney NSW 2001
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Fax: +61 (0) 2 9251 3552
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4. Every new member is entitled to receive Society’s Bulletin (DOS Times) and Annual proceedings of the Society free.

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6. Application for the membership along with the Bank Draft for the membership fee should be addressed to Dr. Amit Khosla,
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New Delhi - 110 060

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Online Journal Available

Dear DOS Members,

The DOS members can get the full text articles of the current issues as well as many back issues of these subscribed
journals. You need to send the request for the article needed via email: [email protected] We will email
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E-mail ID is: [email protected]

1. Acta Ophthalmologica –(2008-2010) 11. International Ophthalmology Clinics –(2000-2010)

2. Acta Ophthalmologica Scandinavica –(2001-2007) 12. Journal of Glaucoma –(2001-2010)

3. Acta Ophthalmologica Scandinavica Supplement –(2002-2005) 13. Journal of Neuro-Ophthalmology –(2001-2010)

4. Archives of Ophthalmology –(1995-2010) 14. Journal of Pediatric Ophthalmology & Strabismus –(2008-2009)

5. British Journal of Ophthalmology –(2008-2010) 15. Journal of Refractive Surgery –(2008-2009)

6. Clinical & Experimental Ophthalmology –(2001-2010) 16. Ophthalmic Plastic & Reconstructive Surgery –(2000-2010)

7. Contemporary Ophthalmology –(2005-2010) 17. Ophthalmic Surgery, Lasers & Imaging –(2008-2009)

8. Cornea –(2000-2010) 18. Ophthalmology Management –(2008-2010)

9. Current Opinion in Ophthalmology –(1999-2010) 19. Retina –(2000-2010)

10. Evidence-Based Ophthalmology –(2008-2010) 20. Techniques in Ophthalmology –(2003-2010)

72 DOS Times - Vol. 16, No. 3, September 2010

www.dosonline.org Allergic Conjunctivitis

History of Itching, Burning, Thick Ropy Discharge

History of Seasonal variation / chronicity Chronic with seasonal History of Contact Lens use
Seasonal Variation + Exacerbations
G.P.C.
ENT Symptoms + Atopy, ENT Symptom Look for papillae
Seasonal Allergy + (0.3mm in diameter or larger
P.A.C. in upper conjunctiva)
Asthma + s Same as SAC
Atopic Dermatitis
S.A.C. V.K.C. Asthma

Look for s Cobblestones in A.K.C.
s Allergic Salute upper tarsal
s Allergic shiners conjunctiva s Lid thickening
s Papillary hypertrophy in + secondary blepharitis
s Maxwell Lyon’s sign
upper tarsal conjunctiva s Trantas Dots on s Entropion
s Dellen s Punctal stenosis
superior limbus s Dennie’s Line
SAC : Seasonal Allergic Conjunctivitis s Pseudogerenotoxon s Limbal nodules
VKC : Vernal Kerato Conjunctivitis s Shield ulcers s Trantas Dots
PAC : Perennial Allergic Conjunctivitis s SPK’s s Inferior tarsal
AKC : Atopic Kerato Conjunctivitis s Pannus
GPC : Giant Papillary Conjunctivitis papillary reaction
s SPK’s & Pannus
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Jasmita Popli MS
Eye Department, Max Healthcare, New Delhi

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