Regional Institute of Ophthalmology, PGIMS, Rohtak

Ignaz Semmelweis

(01.07.1818 - 13.08.1865)

Puerperal fever was common in mid-19th-century hospitals and often fatal. Semmelweis a Hungarian
physician based on his obeservations proposed the practice of washing hands with chlorinated lime solutions in
1847 while working in Vienna General Hospital's First Obstetrical Clinic. He published a book of his findings
titled, “ Etiology, Concept and Prophylaxis of Childbed Fever” Despite various publications of results where
hand washing reduced mortality to below 1%, Semmelweis's observations conflicted with the established
scientific and medical opinions of the time and his ideas were rejected by the medical community. He could offer
no acceptable scientific explanation for his findings, and some doctors were offended at the suggestion that they
should wash their hands and mocked him for it. In 1865, the increasingly outspoken Semmelweis supposedly
suffered a nervous breakdown and was committed to an asylum by his colleagues. He died 14 days later and
Semmelweis's practice earned widespread acceptance only years after his death.
This is because of him that we know the importance of washing our hands, which is the biggest weapon
against COVID-19.

A BIG SALUTE TO
THE CORONA WARRIORS

ESTD 1984

HARYANA JOURNAL OF OPHTHALMOLOGY

Vol. 12 (No.1) ISSN No. 2322-0309 May, 2020

EDITORIAL BOARD

EDITOR-IN-CHIEF
Dr. Manisha Nada

ASSOCIATE EDITOR
Dr. Sunil Verma

EDITORIAL ADVISORY BOARD

Dr. Ishwar Singh Dr. S.V. Singh Dr. Jagat Ram
Dr. R.C.Nagpal Dr. J.P.Chugh Dr. M.R. Dogra
Dr. Amod Gupta Dr. Sunandan Sood Dr. Ashok Garg
Dr. Atul Kumar Dr. Markanday Ahuja Dr. Kapil Vohra
Dr. C.S.Dhull Dr. Sudesh Arya Dr. Lalit Verma
Dr. A.K.Khurana Dr. J.L.Goyal Dr. Ajay Sharma
Dr. Deependra V Singh Dr. Narinder Taneja Dr. I. M. Rustagi
Dr. Rohit Saxena Dr. Jatinder Bali Dr. Vishali Gupta
Dr. S.S. Pandav Dr. R.K.Bansal Dr. R.L.Sharma
Dr. Karamjeet Dr. Subina Narang Dr. Sushmita Kaushik
Dr. Rajeev Tuli Dr. V.K.Dhull Dr. R.S.Chauhan

EDITORIAL COMMITTEE MEMBERS

Dr. Manisha Rathi Dr. Subhash Dadeya Dr. Ramandeep
Dr. Neebha Passi Dr. Urmil Chawla Dr. Sumit Sachdeva
Dr. Ashok Rathi Dr. Chekitaan Singh Dr. Rajan Gupta
Dr. Ashu Aggarwal Dr. Reena Gupta Dr. Sumeet Khanduja
Dr. Neeraj Sanduja Dr. Jitender Phogat Dr. G.C. Gupta
Dr. Mukesh Rathi Dr. Salil Gupta Dr. Aruj K.Khurana
Dr. Neha Adlakha Dr. Satinder Vashisht Dr. Bhawna Khurana
Dr. Harpal Jhagta Dr. Parveen Monga Dr. M.L.Bagla
Dr. Prachi Jain Dr. Parveen Rewri Dr. Ruchi Mittal
Dr. Jyoti Kapoor Dr. Sanjeev Arora Dr. Adviti Arora
Dr. Vivek Dhillon Dr. Anju Bajaj Dr. Jyoti Deswal
Dr. G. C. Rajput

EDITORIAL OFFICE

Prof. MANISHA NADA
Editor-in-Chief, HJO
RIO, Pt. B.D.Sharma PGIMS, Rohtak
Resi: House No. 22/9J, Medical Campus, Rohtak-124001(Haryana)
Mobile 9896007158, E-mail : manisha_nada@rediffmail.com

ESTD 1984

OFFICE BEARERS HOS

Patrons

Dr. C.S.Dhull Dr. A.K. Khurana

President Vice President General Secretary
Dr. Narinder Taneja Dr. Rajender Singh Chauhan Dr. Inder Mohan Rustagi

Chairman Scientific Committee Editor Journal Treasurer
Dr. Urmil Chawla Dr. Manisha Nada Dr. Rajan Gupta

Joint Secretary
Dr. Neeraj Sanduja

Managing Committee Members

Dr. Rajat Mathur (Ambala) Dr. Pushkar Dhir (Bhiwani)

Dr. Amit Arora ( Faridabad) Dr. Deependra V Singh (Gurugram)

Dr. Praveen Monga (Hisar) Dr. Amit Singhal (Jhajjar)

Dr. Satyavan Sharma (Jind) Dr. Vikas Gupta (Kaithal)

Dr. Sanjeev Arora (Karnal) Dr. Rajesh Saini (Kurukshetra)

Dr. Yogesh Kumar (Nuh) Dr. Ashok Gupta (Panchkula)

Dr. V.K.Gupta (Panipat) Dr. Avinash Sharma (Rewari, M.Garh)

Dr. Neebha Passi (Rohtak) Dr. Gaurav Goyal (Sirsa-Fatehabad)

Dr. Ramesh Narang (Sonipat) Dr. Shimmi Talwar (Yamunanagar)

AIOS Managing Committee Members NZOS Managing Committee Members
Dr. Narinder Taneja Dr. Rajat Mathur
Dr. Inder Mohan Rustagi Dr. Inder Mohan Rustagi

MEET THE HOS EXECUTIVES

Dr. C. S. Dhull Dr. A. K. Khurana Dr. Ajay Sharma Dr. Kapil Vohra
Patron
Patron Immediate Past President Former Past President

Dr. Narinder Taneja Dr. Rajender Chauhan Dr. Inder Mohan Rustagi
President Vice President Hony. Gen. Secy.

Dr. Urmil Chawla Dr. Manisha Nada Dr. Rajan Gupta Dr. Neeraj Sanduja
Chairman, Editor, HJO Treasurer Joint Secy.

Scientific Committee

ESTD 1984

CONTENTS

Page No.

President's Message 8
Dr. Narinder Taneja

Message from Immediate Past President 9
Dr. Ajay Sharma

Secretary's report 10
Dr. Inder Mohan Rustagi

Editorial 11-12
Dr. Manisha Nada

Current Topic 13-16
Coronavirus and the Ophthalmologist

Review and Original Articles 17-19

· Artificial intelligence in ophthalmology: an insight
AK Khurana, Harvinder Singh

· How to Minimize/Avoid Medical Error and Litigation during the Ophthalmic 20-24
Practice?
Suresh K. Pandey, Vidushi Sharma Pandey

· Role of newer Diagnostics in Glaucoma- Pattern Electroretinogram (PERG) and 25-31

Optical coherence tomography angiography (OCTA)

Ankita Chaudhary

· Managing ocular allergies in steroid responsive patients 32-34
Parveen Rewri 35-37
38-41
· Biosimilar vs innovator : our experience 42-47
Salil Gupta, Himanshu Goyal 48-52

· Molluscum contagiosum of eye lid an over view
Yash Pal Ranta, R.L. Sharma

· Regional anaesthesia in eye
Sakshi Lochab, Manisha Nada, Jitender Phogat, Aakash Sharma, Monika, Manoj P

· Anti VEGFs for Treatment of Retinopathy of Prematurity
Ritesh Verma, Satvir Singh, Manisha Rathi, Manisha Nada, Sumit Sachdeva, Dixit Soni

· Limbal Stem Cell Deficiency: Etiology, Diagnosis and Management 53-56
Monika, J.P.Chugh, Latika Pandey, Ester, Aakash Sharma, Sakshi Lochab 57-62
63-65
· An overview of specular microscopy
Apoorva Goel , R S Chauhan, Ashok Rathi, J P Chugh, Vandana, Sandhya J 66-69
70-72
· Floppy Eyelid Syndrome: An Overview 73-75
Nisha Bura, Urmil Chawla, Akanksha Rani, Richa Sharma, Reena Gupta, Neebha Anand 76-78
79-80
Case Reports 81-82
83-84
· A rare case of typical Devic's disease 85-88
Sahebaan Sethi, Aditya Sethi, Vaibhav Sethi
89-90
· Welder's Maculopathy- A Case Report 91-95
Nikita Arora, Praveen Arora 96-97

· Congenital lacrimal fistula: a peculiar case 98
AK Khurana, Sonakshi Sehrawat, Urmil Chawla, Saumya Sharma 99
100
· Frontal sinus osteoma presenting with proptosis 101
Raman Wadhera, Keshav Gupta, Manisha Nada

· A giant inclusion cyst following strabismus surgery
Malay Verma

· Traumatic Phacocele : an unusual case
Nikunj Bhat

· Upper lid cicatricial ectropion : A rare case report
Sonakshi Sehrawat, Saumya Sharma, Neeraj Sharma, Raman Sethi

· Intraocular lens calcification- A Nightmare
Preeti Yadav, Manisha Nada, Aakash Sharma, Sunil Kumar Verma, Monika, Satvir Singh

Residents' corner

· Eye care during Covid 19 pandemic
Omesh Kumar Bharti

· Congenital nasolacrimal duct obstruction- what we need to know?
Saurabh Kamal

· Informed consent:Need and the Execution
Parveen Monga

HOS Quiz
Information for Authors
Assignment of copyright form
Membership form
Clip Sheet
HOS Events

President's Message

Dear Friends,

Warm greetings!!

It is a matter of great pride for all the members that we successfully organised 78th Annual conference of AIOS --
AIOC 2020. All of you must be congratulated and applauded for your sincere and dedicated efforts to make the
conference a great success. All this was possible due to the efforts of Prof. AK Khurana Senior Organising
Chairman, Dr Ajay Sharma Organising Chairman, Chief Organising Secretary Prof. Inder Mohan Rustagi, myself
as Organising Secretary and Dr Dheeraj Gupta as Treasurer . We were helped by National Organising Committee
which guided us through and through. We were also helped by GOS and all members of HOS. God has been very
kind as we organized the conference with fear of Corona looming large .
Corona epidemic has engulfed the whole world and the number of positive cases is rising so far in our country . I
wish the whole mankind comes out of this crisis. Please take care of yourself , your family and whole community .
The membership of HOS has reached 936. About 250 are members from other states. There are still many
ophthalmologists in our State, who are not members. I request all of you to please help in enrolling each one in your
city. This is a continuous process as new doctors keep settling in Haryana.
I am very happy that another issue of our Journal is being brought out by Prof. Manisha Nada, Chief Editor.
Congratulations and best wishes to her.
God bless you, God bless HOS to live long.
Jai Hind!
Narinder Kumar Taneja
President

8

Message from the Immediate Past President

Dear Friends,
Greetings.
Our state society is progressing each year. Whether it is the increase in number of members, CMEs, Symposiums
or our magnificent State Conferences, the content of scientific programmes, the quality of faculty , all have seen a
remarkable improvement. AIOC 2020 was a landmark conference because of the efforts of one and all and
everyone needs to be congratulated for the same.
When it comes to Scientific content I have to give a special mention to our , HJO team . Kudos to the team led by
dynamic , Professor Dr. Manisha Nada , who are now ready with the new edition of our state journal. Needless to
say the content is excellent and the hard work put by the team is evident. My best wishes to the team.
The world is passing through a very difficult phase of Covid-19 pandemic. We need to follow the scientific
guidelines and stay positive with a belief that we will come out stronger from these difficult times.
I would like to thank my seniors and colleagues who guide and help us keep HOS so active .
I would like to thank the office bearers and executives of HOS for their overwhelming support during my tenure as
President.
Jai Haryana and Jai Bharat.
Regards!
Dr. Ajay Sharma

9

Secretary's Report

Respected Seniors and Dear Colleagues,

Warm greetings from the desk of honorary general secretary,

Congratulations to Prof Manisha Nada for continuously carrying out the superb work of the journal.
Haryana Ophthalmological Society membership has grown to 936 till now, thanks to the untiring efforts of
Dr. Narinder Taneja and Dr. Rajan Gupta. We welcome all our new members in the society.
AIOC 2020 in Gurugram was a responsibility given to our society and with your blessings and support we could
organize a landmark conference which has set the bar high for the forthcoming events.
Annual Conference of our society was held at Sirsa on September 21 & 22, 2019 and was very well organized by
Sirsa Fatehabad Ophthalmological Society . Kudos to the Chief organizing secretary Dr. Praveen Arora and his
team who had left no stone unturned .
AIOS has been benevolent by allotting us four ARC symposia in a row and this reflects the faith of the national
body in HOS.
Corona crisis has affected every sphere of life and has brought the community activities to a standstill. Let us take a
pledge to fight this menace with sound scientific guidelines and come out victorious from this pandemic. HOS
wishes that all members with their families stay safe and healthy.
Finally I would like to extend my thanks to all my friends, well wishers, my senior colleagues ,family members for
their love and selfless moral support towards HOS concerned activities .
God bless you, God bless HOS to live long.

Jai Hind!
Prof. Dr. Inder Mohan Rustagi
Hon. General Secretary, HOS
Triveni Hospitals Pvt Ltd,
207/13, Subhash Nagar, Old Railway Road,
Gurugram, Haryana - 122001
E-mail : indermohan.rustagi@rediffmail.com
Mobile : 9810093892

10

Editorial

Respected Seniors and Dear Colleagues,

Warm Greetings!

The latest issue of HJO is with you and I am overwhelmed with your support with which I could undertake this
arduous work.
The initial two months of the year 2020 were vibrant, filled with excitement of AIOC at Gurugram, Haryana. It
gave us a sense of fulfillment and satisfaction. Organizing a conference of such a magnitude and that too so
successfully speaks volumes about the growth and strength of our society.
This was followed by wrath of Corona crisis and the world is not the same anymore. The COVID-19 pandemic has
taken the globe by a storm. Every aspect of life is badly affected and we are passing through probably the worst
phase of our lifetimes. The situation is ever evolving with frequent change in guidelines and practices. Adaptation
to the new normal, accepting the challenges and to keep on innovating as the situation evolves will be the key steps
in fight against COVID-19. The 'New Normal' as they call is not easy to embrace and the resilience of humanity is
on test. The practice of Ophthalmology needs to change from ambulatory to virtual as far as is possible to protect
the providers as well as the patients. Telemedicine and Teleophthalmology need to be developed as useful tools.
Artificial intelligence platforms which are already in vogue will be very important to decongest the out patient
departments and simultaneously standardize the healthcare. It appears that the fight against COVID-19 is going to
be a marathon and we need to prepare ourselves for a long battle.
Hydroxychloroquine (HCQ) which is currently used widely for the treatment of rheumatological and
dermatological disorders has made headlines as potential treatment for individuals with SARS-CoV-2 infection.
There have been conflicting reports regarding its use as prophylaxis, however ICMR has recommended it for
prophylaxis in frontline workers in India. Concerns have already been raised potential severe systemic
complications as HCQ has a narrow therapeutic index. It is well recognised that taking HCQ in the long term may
lead to retinal toxicity in susceptible individuals. As it is not possible to determine in whom this will occur in
advance, screening and monitoring programmes are being implemented in many countries. It is very important
that the general public is made aware of the risks of taking these drugs, and their use is carefully monitored, not
only for the potential systemic risks, but also for their potential to cause irreversible blindness.

We must pay our tributes to Dr. Li Wenliang, an ophthalmologist at Wuhan Central Hospital, who lost his life to the
novel coronavirus , SARS-CoV-2 and became the face of the threat of SARS-CoV-2 to frontline workers and the
clinicians taking care of the patients. 'On 30th December, 2019, when the Wuhan municipal health service sent out
an alert, he reportedly warned a closed group of ex-medical school classmates on the WeChat social media site of

11

“Seven cases of severe acute respiratory syndrome (SARS) like illness with links with the Huanan Seafood
Wholesale Market” at his hospital. He was among the eight people reprimanded by security officers for “spreading
rumours”. In a tragic turn of events, he subsequently contracted SARS-CoV-2 and, after a period in intensive care,
died on the morning of Friday 7th February, 2020 (South China Morning Post, 2020).
This pandemic has taught us an important lesson that there is an ever lurking risk of emerging disease outbreaks
for healthcare workers in future also. Public health authorities need to take a serious note of this and plan ahead to
prevent outbreaks of diseases with epidemic potential.
Dr Li Wenliang's example as an astute clinician should inspire all of us to be vigilant, bold and courageous in
reporting unusual clinical presentations.
HJO provides a platform to the members to share their scientific growth and experience. It is heartening to know
that the young budding ophthalmologists and students have contributed immensely to this issue with their
scientific research and this is worth applauding. This is the first E-issue of HJO and we had to resort to online
version due to ongoing COVID-19. This seems to be a positive effect of COVID-19 that we are trying to innovate
as per the prevailing situation. This needs some deep thinking and I take this opportunity to invite comments from
all whether we should continue to have E-issue only in future. Please submit your comments online so that a
decision can be taken in subsequent meetings.
Special thanks to the Patrons Dr. C.S. Dhull & Dr. A.K. Khurana, executives of HOS, our President Dr. Narinder
Taneja, Vice-president Dr. Rajender Singh Chauhan, Secretary Dr. Inder Mohan Rustagi and Treasurer Dr. Rajan
Gupta for their encouragement. I would like to express my appreciation for the efforts of the editorial team
members and each and every member of RIO who showed sincere willingness and contributed their work and time
for this scientific work. My sincere thanks to Sr. Professor Dr. S.V. Singh and Sr. Professor Dr.J.P. Chugh, the
supporting pillars of RIO, Rohtak who have always been helping in my endeavours.
Please feel free to communicate the shortcomings and your suggestions to further improve the journal. Flag of
Ophthalmologists of Haryana must fly high in the National scenario.

Keep your hands sanitized, wear masks and smile!

Stay safe and enjoy reading!!!

Dr. Manisha Nada
Editor-in-Chief, HJO
Professor,
Vitreoretina Unit,
RIO, Pt. B. D. Sharma PGIMS,
Rohtak-124001 (Haryana)
E-mail : manisha_nada@rediffmail.com
Mobile : 9896007158

12

Current Topic

Coronavirus and the Ophthalmologist

Manisha Nada MS,DNB, Aakash Sharma MBBS

Regional Institute of Ophthalmology, PGIMS, Rohtak

Introduction Receptor Affinity

The worldwide outbreak of the severe and acute Angiotensin Converting Enzyme 2 (ACE2),
respiratory coronavirus disease (COVID-19) caused expressed on type I and II alveolar epithelial cells, is
by the coronavirus strain SARS-CoV-2 is currently the receptor for SARS-CoV-2. The type II alveolar
the focal point of discussion due to the suffering cells have more than 80% ACE2 expression. The
caused to humanity. The cases are on a steep rise in binding of SARS-CoV-2 on ACE2 causes an elevated
India. This all started on December 30th, 2019 when expression of ACE2, which can lead to damage of
Dr. Li Wenliang, a young 33-year-old Chinese alveolar cells. Men have a higher ACE2 level in their
ophthalmologist working at the Wuhan Central alveolar cells than women. Asians have a higher level
Hospital in Wuhan, Hubei province, China first of ACE2 expression in their alveolar cells than the
shared about the disease on social media platforms. White and African American populations. The
WHO declared COVID-19 as a pandemic on March receptor binding ability of SARS-CoV-2 is 10 to 20
11, 2020 and it was declared a 'notified disaster' in times stronger than that of SARS-CoV thus making
India on March 14,2020.1 This has been followed by SARS-CoV-2 more infective than SARS-CoV.4
unprecedented lockdowns, government response to
gear up the health machinery, economic measures and Modes of transmission
planned unlocking of the nation but at the time of
writing this article the situation is still evolving and Ÿ Droplet infection by aerosolization from infected
far from being under control. cases (Speaking, coughing, sneezing,
interventional procedures on oropharyngeal
Microbiology airway )

Ÿ Infection via fomites- surface of door handles, cell
phones, and other residential possessions of
confirmed cases

Ÿ Tears in the conjunctival sac of an infected person
also harbor the virus

Ÿ Stool and urine have also been implicated as the
possible media in harboring the infective agent.

Fig. 1: Schematic diagram of coronavirus Pathogenesis

Coronavirus causing Covid-19 is a non-segmented Once SARS-CoV-2 enters the alveolar epithelial
positive-sense RNA virus which belongs to Suborder cells, its fast replication rate triggers a strong immune
Coronidovirinae, familt Coronaviridae and Genus response causing cytokine storm syndrome
Betacoronavirus2 The virus is spherical with (hypercytokinemia) and subsequence pulmonary
approximately 125 nm diameters having club-shaped tissue damage. In general, hypercytokinemias consist
Glycoprotein S projections giving then the crown- of a group of disorders that produce an elevation of the
shaped appearance and hence their name. The virus is pro-inflammatory cytokines. These cytokines are an
enveloped with a protective lipid bilayer containing important cause of acute respiratory distress
four structural proteins viz. spike(S), membrane(M), syndrome (ARDS) and multiple organ failure 6,7,8
envelope(E) and nucleocapsid (N)(Figure 1).3
Viral infection and immune response both can lead to
ocular manifestations, such as conjunctivitis, uveitis,
retinitis, among others. It is difficult to determine the

13

pathogenesis of the ophthalmic involvement. scientific evidence that wearing standard prescription
However, since the virus has been cultured from spectacles provides protection against COVID-19 or
conjunctival secretions9 COVID-19 ophthalmopathy other viral transmissions. When using contact lenses
is more likely to be related to virus infestation. or glasses, careful and thorough washing of hands
with soap and water and subsequent drying with
COVID-19 and Ophthalmologist unused paper towels is extremely important. It is
recommended that disposable lenses should be used if
Ocular involvement in COVID-19 patients can occur possible and use of spectacles should be encouraged
either due to direct viral infection or as a result of over contact lenses.16
immune response to systemic infection. In one study,
one-third of patients with COVID-19 had ocular Elective surgeries
abnormalities, which frequently occurred in patients
with more severe disease.10 Non-urgent elective cataract and refractive surgery
should be currently suspended due to risks associated
Ocular involvement with COVID-19 infection. However, urgent and
emergency eye services must not cease for patients
Various studies suggest that SARS-CoV - 2 usually with sight or life-threatening conditions who require
causes mild follicular conjunctivitis, which is urgent treatment; in some situations phacoemulsification
otherwise indistinguishable from other viral cataract surgery may need to be performed as an
conjunctivitis. keratoconjunctivitis with reduced emergency, for example in the context of glaucoma or
vision has also been reported 11,12 Exact incidence of phaco-vitrectomy for retinal detachment. Emergency
ocular involvement is variable ranging from 0.8% to surgical teams should endeavour to provide services
31%.13 The human eye actually has its own intraocular in keeping with the most up to date guidelines.
renin–angiotensin system, and ACE2 receptors have
been found in the aqueous humor14. As previously The overall situation is still evolving and many
explained, the main receptor for SARS-CoV-2 is the unanswered questions remain and there is a clear need
ACE2 receptor, which indicates that aqueous humor for research regarding the effect of Covid-19 on
could be a target in Covid-19 infection however More ophthalmology.
studies are required to validate this fact. Various
studies indicate that tear and conjunctival secretions Ophthalmologist and 'New Normal'
are not a common route of coronavirus transmission,
given that the majority of COVID-19 patients do not The lockdowns will ultimately be over and slowly the
manifest conjunctivitis. Nevertheless, this route of normalcy will return but this is going to be a 'New
transmission cannot be completely eliminated and Normal' Ophthalmologists will be required to start
ophthalmologists should be aware that any sign of OPD'S, IPD'S and operation theatres along with
conjunctivitis in the clinical setting of respiratory tract emergency services. Social distancing, protective
problem and fever should be considered to be a measures and proper hygiene should be strictly
possible coronavirus conjunctivitis.15 followed to minimize the risk of virus spread.

There are individual case reports of successful Telemedicine and teleophthalmology platforms
antiviral therapy with topical use of valaciclovir and should be developed so that unnecessary visits of
ganciclovir.12 Therapeutic antiviral drugs have not patients are avoided and clinicians should postpone
been found very useful and only symptomatic those outpatient visits and procedures that can be
treatment is recommended. Primary infection via the safely delayed, particularly in elderly patients and
conjunctiva leading to systemic involvement, is those with co-morbidities. A definite protocol for
possible but has not yet been fully investigated. appointments should be developed and Out patient
departments should be restructured so that a minimum
Contact lenses distance (at least 1.5 m) between patients is
maintained in waiting area. Protective screens for
There is currently no evidence to suggest an increased medical personnel on registration counters and slit-
risk of contracting COVID-19 through contact lens lamp breath shields (Figure 2) to protect both health
(CL) wear compared to spectacle lens wear and no care workers and patients from respiratory illness

14

should be provided. Direct ophthalmoscopy should long term impact on vision due to loss of regular
not be performed. There should be ample availability follow ups. It will also be important to provide
of sanitizers and soaps, examination gloves, paper education to our patients about the safeguards that
napkins and patients should be asked to wear masks. have been placed to protect them from being exposed
Clinicians should be wearing N95 masks and eye to COVID-19. This may present an opportunity to
shields/goggles.13 It is better to change to surgical explore novel technologies such as video consultation
scrubs in your clinics. and home monitoring.

The diagnostic eye drops that are needed for COVID-19 can be compared to a moving target where
ophthalmological examinations should be provided new data is coming at a rapid rate. The
as single-dose eye drops to prevent virus spread as ophthalmologist is required to keep abreast with latest
much as possible. In the case of diagnostic eye drops developments and provide patient care and self care as
that cannot be provided as a single dose, it is important per evolving scientific evidence.
to ensure correct application without eye or eyelid
contact so as not to contaminate the eye drop bottles. References
As far as possible single-use products should be used.
This applies in particular to tonometer heads, since 1. Available from: https://en.wikipedia.org/ 2019-
they are in direct contact with the surface of the eye.13 20 Coronavirus pandemic. [Last accessed on
2020April 11].
In the case of inpatient stays, screening for COVID-
19 should be carried out, when the patient is admitted. 2. Coronaviruses: An Overview of Their
It is also recommended that patients be given detailed Replication and Pathogenesis. Fehr, Perlman:
information about the hygiene and distance rules Methods Mol Biol, 2015; 1282: 1–23.
during their stay, including in the patient room. Visits
to the sick should be avoided wherever possible. 3. Prasad S, Potdar V, Cherian S, Abraham P, et al.
COVID-19 positive patients are to be admitted and Transmission electron microscopy imaging of
treated in dedicated COVID wards. SARS-CoV-2. Indian J Med Res. 2020. Feb-
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HCQ
4. Zhang H, Penninger J, Li Y, Zhong N, Slutsky A.
Ophthalmologist could possibly play a larger role in Angiotensin-converting enzyme 2 (ACE2) as a
the screening of side effects of possible COVID-19 SARS-CoV-2 receptor: molecular mechanisms
therapeutics. Chloroquine and hydroxychloroquine, and potential therapeutic target. Intensive Care
have shown promise in non-randomized trials and Medicine. 2020;46(4):586-590.
there are ongoing trials to investigate their safety and
efficacy in the treatment of COVID-19. 5. Available from:
https://www.aao.org/headline/Alert:Important
The risk of irreversible maculopathy by chloroquine Coronavirus update for ophthalmologists.
and hydroxychloroquine should be informed to the [Last accessed on 2020 Mar 26].
patients/healthcare workers before starting therapy.
History of previous or coexisting ocular disease 6. Villar J, Zhang H, Slutsky AS. Lung repair and
should be obtained. The need for initial fundus regeneration in ARDS: role of PECAM1 and
examination, Bscan, ERG etc. is not established as yet Wnt signaling. Chest. 2019;155:587–594. doi:
and decisions should be made on an individual basis. 10.1016/j.chest.2018.10.022.
Whether a screening for maculopathy is necessary
and how it will develop will be shown as soon as the 7. Channappanavar R, Perlman S. Pathogenic
first study results on this topic are published.17 human coronavirus infections: causes and
consequences of cytokine storm and
Post lockdown challenges-Non Covid diseases immunopathology. Semin Immunopathol.
2017;39:529–539. doi: 10.1007/s00281-017-
Key area of concern will be the long-term effects on 0629-x.
vision as a result of this period of disruption in care.
Clinical cancellation and postponement of non- 8. Wang H, Ma S. The cytokine storm and factors
essential treatments in view of COVID-19 will have determining the sequence and severity of organ
dysfunction in multiple organ dysfunction
síndrome. Am J Emerg Med. 2008;26:711 715.

15

doi: 10.1016/j.ajem.2007.10.031.

9. Chen L, Liu M, Zhan Z, et al. Ocular
manifestations of a hospitalised patient with
confirmed 2019 novel coronavirus disease. Br J
Ophthalmol. 2020 doi: 10.1136/bjophthalmol-
2020 316304.

10. Wu P, Duan F, Luo C, et al. Characteristics of
ocular findings of patients with coronavirus
disease 2019 (COVID-19) in Hubei Province.
China JAMA Ophthalmol. 2020.
https://doi.org/10.1001/jamaophthalmol.2020.1
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11. Zhang X, Chen X, Chen L, Deng C, Zou X, Liu
W, Yu H, Chen B, Sun X. The evidence of
SARS-CoV-2 infection on ocular surface.
Ocul Surf. 2020 Jul; 18 (3): 360-362.

12. Cheema M, Aghazadeh H, Nazarali S, et al.
Keratoconjunctivitis as the initial medical
presentation of the novel coronavirus disease
2019 (COVID-19) Can J Ophthalmol. 2020 .

13. Alexander C. Rokohl , Niklas Loreck ,
Philomena A. Wawer Matos , Joel M. Mor ,
Sarah Zwingelberg , Rafael S. Grajewski , Claus
Cursiefen ,and Ludwig M. Heindl. The role of
Ophthalmology in Covid 19 patients.
Ophthalmologist . 2020 Jun 9: 1-6.German. doi:
10.1007 / s00347-020-01148-9.

14. Holappa M, Vapaatalo H, Vaajanen A Many
Faces of Renin-angiotensin System Focus on
Eye.Open Ophthalmol J 2017; 11():122-142.

15. María A. Amesty, Jorge L. Alió del Barrio, and
Jorge L. Alió COVID-19 Disease and
Ophthalmology:An Update.

b. Ophthalmol Ther. 2020 May 22 : 1–12doi:
10.1007/s40123-020-00260-y.

16. Lyndon Jonesa, Karen Walshb, Mark Willcoxc,
Philip Morgand, Jason Nicholse. The COVID-
19 pandemic: Important considerations for
contact lens practitioners. Contact lens and
anterior eye.2020;43:196-203.

17. Ruamviboonsuk P, Lai T, Chang A, Lai C,
Mieler W, Lam D. Chloroquine and
Hydroxychloroquine Retinal Toxicity
Consideration in the Treatment of COVID-19.
Asia-Pacific Journal of Ophthalmology.
2020;9(2):85-87.

16

Artificial intelligence in ophthalmology: an insight

AK Khurana MS, Harvinder Singh MBBS

Department of Ophthalmology, SGT Medical College,
Hospital and Research Institute, Budhera, Gurugram

Abstract

Artificial intelligence (AI) has been studied in ophthalmology since availability of digital information in
ophthalmic care. AI could potentially revolutionize how ophthalmology is practiced in the future. Although AI has
broad application across many medical fields, it will have particular utility in ophthalmology and will
dramatically change the diagnostic and treatment pathways for many eye conditions. The significant turning
point was availability of digital color fundus photography in the late 1990s, which caused digital screening for
(DR) to take off. Automated Retinal Disease Assessment software was then developed using machine learning to
detect abnormal lesions in fundus to screen DR. In future, the concept of artificial intelligence is going to play a
major role in ophthalmology as software and other technical aspects will help the ophthalmologists in validation,
testing and early diagnosis of the diseases. This review discusses developments and potential practices regarding
the use of artificial intelligence in the field of ophthalmology.

Keywords: Artificial intelligence, ophthalmology, diabetic retinopathy, digital screening, machine learning

Introduction Machine Learning: The term “machine learning”,
one of the subclasses of artificial intelligence
Artificial intelligence (AI) is a general term that frequently used in ophthalmology studies, was first
means to accomplish a task mainly by a computer, introduced in 1959 by the engineer Arthur Samuel, a
with minimal human beings involved.1 The term pioneer in artificial intelligence. He defined this term
“artificial intelligence” was likely coined during a as the ability of machines to learn outcomes that are
conference at Dartmouth College in 1956. The not explicitly programmed. In the machine learning
earliest work of medical AI dates back to the early technique, the aim is to generate an algorithm based
1970's.2 The field of ophthalmology is well suited for on a certain amount of data entered into a computer
artificial intelligence studies, with its numerous and for the computer to then use this algorithm to
digital techniques such as color fundus photography, improve its predictions. Machine learning provides
optical coherence tomography (OCT), and techniques or algorithms that can automatically build
computerized visual field (VF) testing and the huge a model of complex relationships by processing the
databases they provide. In addition to this, the global input available data and generalizing a performance
increase in life expectancy is accompanied by an standard.6
increase in eye diseases that cause preventable vision Deep Learning: DL research in ophthalmology has
loss.3,4 The strengths in the field of ophthalmology in progressed rapidly, and has the potential to become a
India is availability of huge number of patients even part of daily clinical practice in the relatively near
for rarest diseases and good number of centers of future. In the same way that an electrocardiogram
excellence in eye care across the countries, making machine can provide a relatively accurate reading of
them a perfect platform for developing AI algorithms. the electric function of the heart, DL algorithms are
The government think-tank, National Institution for now offered by a number of private companies that
Transforming India (NITI) Aayog, spearheads a focus on screening for retinal disease including
national program onAI focusing on research in India.5 diabetic retinopathy and macular degeneration. In
coming time, DL algorithms may become
Components ofAI incorporated into many digital ophthalmic diagnostic
AI is umbrella term that encompasses multiple tools. DL can also be applied to teleophthalmology
components, namely machine learning and deep
learning.

17

programs to compare normal from abnormal retinal neonatology screening programs.12
images thereby decreasing the number of images sets
reviewed by the ophthalmologists. As sensitivity and AI and Glaucoma
specificities improve for DL systems, the number of AI models are also being expanded to the field of
images sets to review will be reduced, improving glaucoma. Glaucoma is among the leading causes of
access to underserved communities by minimizing vision loss worldwide and has also attracted the
clinician time and alleviating clinician scarcity.6 attention of artificial intelligence researchers due to
AI applications are being developed for many the importance of its early diagnosis and treatment.
different eye diseases, particularly diabetic Multiple groups have looked at machine learning
retinopathy (DR), age-related macular degeneration models for the diagnosis of glaucoma using available
(AMD), glaucoma, and retinopathy of prematurity data such as visual fields, optical coherence
(ROP), which are the leading causes of vision loss. tomography, and optic disc characteristics. In coming
time, the practicing ophthalmologist will have a host
AI and Diabetic Retinopathy of tools available to diagnose glaucoma, detect
The most important use of AI in ophthalmology is for disease progression and identify optimized treatment
the evaluation of DR from fundus photographs, which strategies using a precision medicine approaches. In
has several studies and reviews.7 The FDA approved future, they may also have clinical forecasting tools
autonomous AI diagnostic device was IDX-DR for that inform patients as to their overall prognosis and
detecting more than mild DR and diabetic macular expected clinical course with or without treatment.13
edema. Fundus images taken using a fundus camera
are collected and evaluated later or they are uploaded AI and Age-Related Macular Degeneration
through the internet to the powerful server which (ARMD)
generates the report and sends it back to the device. ARMD is a chronic and irreversible macular disease
With the advent of low-cost smartphone-based fundus characterized by drusen, retinal pigment changes,
cameras such as DIYretcam, T3retcam, MIIretcam, choroidal neovascularization, hemorrhage, exudation
JaizRetcam and Hopescope quick image analysis and even geographic atrophy. It is one of the leading
would be invaluable.8 In a recent study, Sosale et al. causes of central vision loss in people aged over 50.
evaluated an offlineAI on a Remidio Fundus-on-Phone With the social population aging and the severity of
and showed a high sensitivity (93%) and specificity this disease, it's necessary to perform AMD screening
(92.5%). Offline AI would make this technology regularly. Automatic AMD diagnosis may obviously
accessible in areas with poor network connectivity.9 reduce the work load of clinicians and improve
efficiency.14 Venhuizen et al. analyzed AMD OCT
AI and Retinopathy of Prematurity data for screening purposes, not only in a binary
The most significant artificial intelligence advances in approach as mentioned earlier but also dividing 367
pediatric ophthalmology apply to ROP, a leading cause individuals into 5 different grades for diagnostic
of childhood blindness worldwide.10 In addition to the grading/staging: no AMD, early AMD, intermediate
shortage of trained providers, ROP examinations are AMD, advanced AMD geographic atrophy and
difficult, clinical impressions are subjective and vary advanced AMD choroidal neovascularization. The
among examiners, and disease management is time overall sensitivity and specificity reached 98% and
intensive, requiring several serial examinations.11 91%. Depending on the different diagnostic stages,
Artificial intelligence applications have focused on different treatments and individual prognoses will be
detecting the presence and grading of ROP or plus the consequence which requires advanced medical
disease from digital fundus photos. Beyond the and legal control.
benefits of automated ROP screening and objective
assessment, digital retinal imaging may cause less Conclusion
pain and stress for infants undergoing ROP screening The age of Artificial Intelligence has definitely
compared with indirect ophthalmoscopy and enable arrived. It may be useful to increase efficiency of
assessment so that more time could be available for

18

patient interaction. AI-based detection and integration Lakshmikanthan C, Krishna S, Sundaramoorthy
is not an alternative but a necessity. AI platforms offer SK. Smartphone-based fundus camera device
the patients more medical opportunities and reduce (MII ret cam) and technique with ability to
obstacles to access for an eye care where an image peripheral retina. Eur J Ophthalmol.
ophthalmologist is not available. To some extent, new 2016; 26:142-144.
technologies based on AI may reduce social 9. Sosale B, Sosale AR, Murthy H, Narayana S,
inequalities. A collaborative approach is the only path Sharma U, Gowda SG, et al. 51-OR: Medios – A
towards meaningful insight by big data analysis which smartphone-based artificial intelligence
may strengthen the entire field substantially and raise algorithm in screening for diabetic retinopathy.
overall quality. AI has the potential to aid in providing Diabetes .2019;68.
medical care for non-specialized hospitals to improve 10. Gilbert C. Retinopathy of prematurity: a global
quality of care for specialty and rare diseases through perspective of the epidemics, population of
pre-screening, evaluation and treatment suggestions. babies at risk and implications for control. Early
Looking further into the future, AI-assisted system Hum Dev. 2008;84: 77–82.
shows the potential to relieve the overburdened 11. Wallace DK, Quinn GE, Freedman SF, Chiang
healthcare system's problems. Ophthalmologists MF. Agreement among pediatric ophthalmologists
should know about the AI resources available to them in diagnosing plus and pre-plus disease in
and make judicious use of them when understanding retinopathy of prematurity. J AAPOS. 2008;
their limitations. 12:352–356.
12. Moral-Pumarega MT, Caserı´o-Carbonero S,
References De-La-Cruz-Be´ rtolo J, et al. Pain and stress
1. Hamet P, Tremblay J. Artificial intelligence in assessment after retinopathy of prematurity
screening examination: indirect ophthalmoscopy
medicine. Metabolism 2017; 69S:S36-S40. versus digital retinal imaging. BMC Pediatr.
2. Patel VL, Shortliffe EH, Stefanelli M. The 2012; 12:132.
13. Li Z, He Y, Keel S et al. Efficacy of a Deep
Coming of Age of Artificial Intelligence in Learning System for Detecting Glaucomatous
Medicine. Artificial Intelligence in Medicine. Optic Neuropathy Based on Color Fundus
2009; 46:5-17. Photographs. Ophthalmology. 2018 Mar 2. pii:
3. Arias E, Heron M, Xu J. United States life tables, S0161-6420(17)33565-0.
2014. NatlVital Stat Rep. 2017; 66:1-64. 14. Chou CF, Cotch MF, Vitale S, Zhang X, Klein R,
4. Zheng Y, He M, Congdon N. The worldwide Friedman DS, Klein BE, Saaddine JB. Age-
epidemic of diabetic retinopathy. Ind J related eye diseases and visual impairment
Ophthalmol. 2012; 60:428-431. among U.S. adults. Am J Prev Med.
5. Resnikoff S, Lansingh VC, Washburn L, et al. 2013;45(1):29-35.
Estimated number of ophthalmologists
worldwide (International Council of Address for Correspondence:
Ophthalmology update): will we meet the
needs? Br J Ophthalmol. 2019 doi: Prof.AK Khurana
10.1136/bjophthalmol-2019-314-336. Dept. of Ophthalmology
6. Lee A, Taylor P, Kalpathy-Cramer J, Tufail A. SGT Medical College,
Machine learning has arrived. Ophthalmology. Hospital and Research Institute, Budhera, Gurugram.
2017;124(12):1726-1728. E-mail :drkhurana8@gmail.com
7. Raju B, Raju NS, Akkara JD, Pathengay A. Do it Mobile: 9255583523
yourself smartphone fundus camera –
DIYretCAM. Ind J Ophthalmol. 2016;
64:663-667.
8. Sharma A, Subramaniam SD, Ramachandran KI,

19

How to Minimize/Avoid Medical Error and
Litigation during the Ophthalmic Practice?

Suresh K Pandey MS, Vidushi Sharma Pandey MD,FRCS,

Suvi eye institute & lasik laser center, Kota, Rajasthan

Abstract

Doctors need to have a clear understanding of how the legal system works. A good doctor–patient relationship is
the foundation of efficient service delivery, as effective communications help both the doctor and the patient to
understand each other's perspective. For the ophthalmologists it is imperative to take substantial measures to
ensure that due diligence is taken in performing surgical procedures and guidelines are followed. Surgical
checklists, protocols, proper documentation (maintaining medical records), taking informed consent,
communication about the outcome of the procedure or treatment, timely referral of the patient (in case of any
complication) and obtaining adequate professional liability insurance are few important tips which can minimize
the risk of litigation against the ophthalmologists.

Keywords: Litigation, documentation, informed consent.

Introduction the ophthalmologists' end can lead to severe
consequences including lifetime blindness and visual
The practice of medicine is capable of rendering noble impairment of the patient. Several cases have been
service to humanity provided with due care, sincerity, reported against ophthalmologists and decisions have
efficiency, and professional skill is observed by the been taken by the National Consumer Disputes
health professionals. Therefore the profession of Redressal Commission (NCDRC). It is reported that
medicine is considered to be one of the noblest 942 cases of medical negligence were decided by the
professions in the world. While we are making NCDRC from 2002 to 2018 and, out of these cases, 30
tremendous progress on the global map, on the were related to ophthalmology. A total of 73.3% of the
contrary, doctor–patient relationship is deteriorating, alleged cases of medical negligence in ophthalmology
our internal medical setup is facing extensive were proved, and compensation for the cases ranged
problems with medical litigation being the most between Rs. 200,000 and Rs. 10 million.2
serious of all issues. Many doctors are charged for
their lack of diligence, leading to litigations in the Such deplorable numbers compel the fraternity to
consumer courts and civil or criminal courts. India is indulge in evaluating the reasons behind the
rapidly becoming one of the main destinations for prevalence of such practice and efforts should be done
medical tourism. With highly advanced medical to educate and sensitize ophthalmologists to minimize
setups, healthcare centers equipped with the latest such cases. There are several cases taking place
medical technology and internationally trained frequently which continue to raise questions against
medical professionals, India is making a name in the the quality of practice being led by the ophthalmologists
global health care industry. Offering reasonable, less in the country. In some instances, the judgment was
expensive and efficient alternatives to complex given against the ophthalmologist even for
medical procedures, patients from different countries complication well reported in the published literature.
prefer to have their treatment and surgeries in India.1 For example, an ophthalmologist in Gujarat was
asked by the consumer court to pay Rs. 100,000
Increasing consumer cases/compensation against compensation to a patient for vitreous hemorrhage
ophthalmologists following an anti-VEGF (Avastin) injection in the
Ophthalmology, in this respect, is no different from patient's eye, leading to temporary blindness.3
other medical sectors. Being one of the most complex Vitreous and retinal hemorrhage have been reported
and high-tech specialties, even the slightest error from as complications of intravitreal injection in the

20

published ophthalmic literature; however, as per court documentation, B: Be clear and consistent,
judgment, this case was clearly one of negligence and communicate effectively to explain pros and cons of
deficiency in service. treatment and establish good patient relationship, C:
In another case reported from Punjab (2017), the State Consent, Checklists to avoid errors.
Consumer Disputes Redressal Commission passed a When it comes to medical negligence, it is an
judgment against the hospital and the accepted fact that the ophthalmologists operate in
ophthalmologists for their medical negligence in the spheres where the success and failure of a case depend
treatment of the patient and failure to produce the on various factors that may or may not be in the
pertaining medical records.4 The complainant was control of the professional (for example contaminated
suffering from diabetes for 13 years and was on irrigating solution). However, negligence is not
antidiabetic drugs. According the court, the medical something that can be overlooked. If the legal
professionals did not produce any medical record definition of the term is looked up to, it is the standard
showing that the required measures were taken to of conduct that is to be observed under all likely
control the blood sugar and blood pressure before circumstances.6 Train your staff members and OT
conducting the surgery. Also, the hospital team did not team to follow the checklist and protocols to minimize
take valid consent from the complainant before any error(s). Double check the consent signed by the
conducting the laser treatment and did not disclose patient, site of operation, and medical records etc.
any risk or complication involved in the process. The before taking the patient in the OT, check the IOL type
decision was passed against the hospital and a and its power, carefully inspect the irrigating solution
compensation of Rs. 2, 00,000 was awarded to the for any floating particles, always cross check date of
complainant's heirs.5 expiry of drugs and devices. Always follow the
In light of the above-mentioned cases, it is evident practice to minimize postoperative endophthalmitis
why there are a rising number of legal cases against such as application of adhesive drapes, preoperative
ophthalmologists. It is extremely important for all cleaning of eye and periocular area with 5% povidone
ophthalmic colleagues to follow the checklist, take iodine solution and instillation of one drop of
informed consent, explain the pros and cons of povidone iodine solution after completion of
treatment and document it in medical records, and an intraocular surgery.
overall due diligence carried out in this specialty. It is Exercising utmost care while performing eye surgery
recognized that human error is the root cause of such or giving intra-vitreal injections is important as
breaches in patient safety—either preoperatively or patient is actively listening all conversation and may
intra-operatively—and at least some are preventable. (wrongly) correlate negligence in case of lack of
Major risk factors for mistakes related to high-volume desired results. Most of the eye surgeries are done
ophthalmic surgery include a breakdown in under topical or local anesthesia with the doctor
communication between the surgeon and the patient speaking to their staff or anesthetists and the patient
and team, the lack of verification procedures (e.g. hearing everything.
incorrect IOL power), inadequate validation of site The main factor behind increased penalties against
marking procedures (e.g. surgery in the wrong eye), ophthalmologists concerning medical negligence is
inadequate preoperative checklists, incomplete greater consumer awareness as well as information
patient assessment, staff distractions, limited or about diseases and treatment available on Internet
compromised information available in the operating (“Dr. Google”). The patients are now more aware of
room, and cultural or language barriers that may not their consumer rights and are provided forums and
be uncommon during high-volume eye surgery. legal means to pursue their claims against the
doctors.7 This awareness has led many
ABC to Minimize Medical Error and Litigation ophthalmologists to unnecessary legal charges, and
ABC to minimize medical error during ophthalmic the decision against doctors are published by the
practice include: A: Accurate and complete media houses prominently encouraging other patients

21

to follow the same route. Never criticize or disapprove complications are included. With 11 out of 30 cases
treatment or surgery done by your professional having a deficiency of service at the postoperative
colleague in front of patients or relatives as it can stage shows that ophthalmologists are not as vigilant
provoke them to file malpractice lawsuits. in maintaining good communication with the patients
The increased cost of service delivery has ultimately or taking enough time to go through the postoperative
led the consumers to have higher expectations from measures to ensure a healthy recovery. As a result, the
the medical providers. Combined with the increased chances of infections and complications increase,
awareness and the availability of means to vocalize leading to alleged medical negligence cases.
their grievances, patients can highlight cases of There is a dire need of maintaining a practice of good
negligence even for the smallest deficiency in the interpersonal skills with the right approach taken to
follow the checklists (at each and every step) and
service. maintain proper documentation. This will not only
Documentation and maintenance of ensure better service delivery but will curtail the
medical records chances of legal suits carried against the doctors and
hospitals.9
The perceived loss of vision is the second-highest
probability after death. This increases the chances of Free eye camps versus litigation: lessons to be
litigations carried out against ophthalmologists. With learned by every eye surgeon
higher treatment cost and more possibility of damage
as compared to other specialties, ophthalmologists The complications in the ophthalmic procedures can
are more inclined towards getting complaints lead to severe consequences including complete or
registered against them. partial blindness and visual impairment. With a higher
According to a study, there are 31.25% proved cases risk of complications, the practitioners must show
of medical negligence.8 An analysis of the diligence not just during the operation but in the pre
ophthalmology-related cases carried out by Yadav, and postoperative stages as well. Any information
Bansal, and Garg (2018) states that 14 cases out of 30 overlooked or prior medical condition deliberately
were reported to have a deficiency of service present undermined can lead to severe consequences for the
at the postoperative stage and one case at the patient and subsequently, legal problems for the
preoperative stage.2 ophthalmologist, too.
The preoperative stage entails taking valid informed
consent (video consent in all high risk cases) of the The case of one of the eye hospitals from Trichy
patient for executing the proposed treatment, taking (Tamil Nadu) before the Madurai Bench of Madras
and recording the history of the patient, carrying out a High Court on 10 September 2018 is one of the
proper examination, diagnosis and investigations, primary examples of how perceived deficiency at
preanesthetic check-up, detailed counseling, service during ophthalmic procedures can cause
complete systemic and ophthalmic investigations and substantial legal charges against doctors.10 The case
then treatment. was filed against three senior executives, two medical
The operative stage includes the complications officers, and an ophthalmic technician of one of the
encountered during the operation, accidents, and eye Hospital in Trichy for deficiency of service
mishaps experienced while operating, (for example causing 61 patients to lose their vision of the operated
implanting wrong IOL), death during operation, and eye, and 5 patients partially losing the vision of their
other similar incidents. Always take help of operated eye.
anesthesiologist for monitoring vital parameters after
taking patients in the operation theater. The allegations against the hospital included:
Under the postoperative stage, operative notes,
discharge, follow-up advice, detailed instructions l Running the hospital without taking legal consent
about using the medications/eye drops, and from Tamil Nadu Pollution Control Board.
communication about the postoperative
l Improper design and maintenance of operation
room.

l No separate room available for sterilization and

22

storage of medicines. for such camps to minimize the complications.
l No appointment of anesthetist to assist the Offering services at a lower (or free of) cost should not
mean comprising the nobility of the profession and
cataract operation but ophthalmic technicians putting the patients at risks knowingly.
were utilized for the purpose.
l No pharmacist was appointed to Eye Hospital. In such circumstances, the blame should not be put on
l Hospital was allowed to function without a the doctors completely as they are pressurized by
laboratory or laboratory technician to conduct a various factors like extending services to rural areas
blood, urine test. that lack proper medical setup, limited funds provided
l No measures taken to check for illnesses such as to organize these camps, and the shortage of trained
diabetes, chronic pulmonary conditions, staff. To minimize litigations in such situations, it is
cardiovascular conditions, and renal condition. mandatory to take all possible measures for caution,
l No trained staff for sterilization available at the and guidelines are to be followed. This will ultimately
time of operation in the operation theater. protect the doctor in case any allegation is being
l The mass postoperative infection was not reported carried out against a doctor.
to the District Medical authorities by the accused.
l Families of the victims were not informed about How Medical/Ophthalmic Societies Can Play
the incident.
l Ophthalmic technician utilized for the service was Important Role?
not qualified as an anesthetist.
Ophthalmic societies (such as All India Ophthalmic
Three of the seven members of the hospital team were Society, AIOS) must include more sessions in the
sentenced to one-year imprisonment for annual conferences to sensitize its members about
complications related to the cataract surgeries how to avoid litigation during clinical practice.
because of the clinical negligence carried out before, Members of AIOS can share tips that can be published
during, and after the cataract surgeries. The hospital in the Indian Journal of Ophthalmology.11 Every effort
was ordered to pay Rs. 0.22 to Rs. 0.57 million as must be made to extend the legal support for the
compensation to the victims. members whenever they are in trouble. The society
should handle the print and electronic media to
At important point to note here is that these surgeries publish the news in a balanced way.
were carried out at an eye camp in Perambalur (Tamil
Nadu). The services were offered at a lower cost and Take Home Message
in a charitable camp. Complications are more likely in
such situations. In the above-mentioned case, the Doctors need to have a clear understanding of how the
patients suffered mass infection (endophthalmitis) legal system works and what consequences they
because there was no proper operation theater setup or might face in what circumstances. Alongside,
any proper team aligned to carry out the cataract establishing good communication with the patients is
surgeries. Because eye camps are organized with important before, during, and after the operative
limited funds and limited resources, it is impossible to procedures. This is necessary for understanding the
lace them with the required technology and staff. exact health condition and history of the patient. A
good doctor–patient relationship is the foundation of
This raises the question that if the eye camp setups efficient service delivery, as effective communications
should be prohibited and the rural population should help both the doctor and the patient to understand each
be compelled to travel to bigger cities and pay hefty other's perspective. This ultimately minimizes the
costs for the surgeries. The answer is no. Eye camps chances of mishaps leading to legal suits.
should not be closed off. Instead, the hospitals and eye
camp in-charge should carefully follow proper The number of cases against eye care professionals
checklists, preoperative systemic and ocular for malpractice is increasing because of the increased
investigations, taking detailed consent, and taking all awareness among the patients. While some cases are
necessary precautions related to Operation Theaters legitimate and based on clinical negligence exercised
by the doctors, most doctors are wrongfully accused

23

because of the lack of public understanding. The eye 6. Moffett P, Moore G. The standard of care: Legal
care professionals must emphasize diligent service history and definitions: The bad and good news.
delivery and also maintain proper records about the West J Emerg Med. 2011;12:109-112.
patient history, consent, and treatment. This practice
will bring down the incidents of malpractice, and will 7. Parikh PM. Consumer protection act: What
protect the doctors from allegations and fake lawsuits. doctors need to be cognizant of? Ind J Med Sci.
For the ophthalmologists in India, it is imperative to 2016;68:2-4.
take substantial measures to ensure due diligence
while performing surgical procedures, and follow the 8. Yadav M, Rastogi P. A study of medical
provided guideline and take all necessary measures negligence cases decided by the district
before performing any surgery in the hospital or in consumer courts of Delhi. J Indian Acad
remote areas during eye camps. Following surgical Forensic Med. 2015;37:50-55.
checklists, protocols, proper documentation
(maintaining medical records), taking informed 9. Chung CH. Case scenarios for optometrists,
consent, communication about the outcome of the opticians, ophthalmologists and family
procedure or treatment, timely referral of the patient physicians [Book Review]. Medico-legal and
(in case of any complication) and obtaining adequate ethical issues in eye care- Hong Kong. J Emerg
professional liability insurance are few important tips Med. 2010;17:101.
to minimize risk of litigation against
ophthalmologists. 10. Dr. Nelson Jesudasan vs State Represented By on
19September,2018[Internet]. I n d i a n k a n o o n . o rg .
References 2019.
1. Crooks VA, Turner L, Snyder J, Johnston R, https://indiankanoon.org/doc/63289652. [Last
cited on 2019 Aug 22].
Kingsbury P. Promoting medical tourism to
India: Messages, images, and the marketing of 11. Pandey SK, Sharma V. Commentary: Increasing
international patient travel. Soc Sci Med. cases of litigationsagainst o p h t h a l m o l o g i s t s :
2011;72:726-732. How can we minimize litigations during
2. Yadav M, Bansal MK, Garg P. Ophthalmology ophthalmic practice?.
Medical Negligence Cases Decided by Ind J Ophthalmol. 2019;67:1527-1530.
NCDRC: Retrospective Study. Indian Internet J
Forensic Medicine & Toxicology. Address for correspondence:
2018;16:64-68.
3. Eye specialist to pay patient: Eye specialist Dr. Suresh K Pandey
orderedtopay patientRs 1 lakhfor negligence | Director, Suvi Eye Institute & Lasik Laser Center,
Ahmedabad News-Times of India [Internet]. The C 13 Talwandi, Kota, Rajasthan. 324005, India.
Times of India. 2019. E-mail:suresh.pandey@gmail.com
https://timesofindia.indiatimes.com/city/ahmed Moblie: +91-9351412449
abad/eye-specialist-ordered-to-pay-patient-rs-
1-lakh/articleshow/66873075.cms.
4. Kumar S. vs Sharma Eye Care & Hospital on 9
May, 2017 [Internet]. Indiankanoon.org. 2019.
https://indiankanoon.org/doc/41019343/
5. Kumar S. vs Sharma Eye Care and Hospital on 9
May, 2017 [Internet].
https://www.casemine.com/judgement/in/56f95
96a4a932658e9cc9f17.

24

Role of newer Diagnostics in Glaucoma- Pattern
Electroretinogram (PERG) and Optical coherence
tomography angiography (OCTA)

Ankita Chaudhary

MS, FICO, FRCS (Glasgow)
Vista Healthcare Clinic, Dubai

Abstract

Glaucoma is a chronic progressive optic neuropathy characterized by loss of retinal ganglion cells (RGCs) and a
leading cause of blindness worldwide. Early diagnosis of glaucoma is essential so that irreversible loss of RGCs
and blindness can be avoided. Available diagnostic modalities are unable to diagnose the disease at its conception
resulting in many suspects. Recently, lots of interest is being shown in the newer diagnostic modalities like pattern
electroretinogram (PERG) and optical coherence tomography angiography (OCTA). These detect the function of
RGCs and the vessel density of optic nerve head which might be affected early before any visible damage. This
article briefly discusses the role of these novel diagnostics in glaucoma.

Keywords: Glaucoma,pattern electroretinogram,optical coherence tomography angiography.

Introduction a variety of techniques and have shown a reduction in
optic nerve head (ONH) perfusion in patients with
Glaucoma is a leading cause of irreversible blindness glaucoma. However, each of these techniques has
worldwide1 and the second most common cause of certain limitations.13 Optical coherence tomography
blindness in the developed world.2 The angiography (OCTA) noninvasively images the blood
pathophysiology of glaucoma is complex and vessels of the ONH and retina in vivo.14 Vessel density
characterized by the time-dependent loss of retinal measurements provided by OCTA have been reported
ganglion cells (RGCs) and their accompanying to be repeatable and reproducible.15-19 A reduction in
axons.3 Indices that are currently used to quantify and vessel densities within the ONH, the peripapillary
evaluate progression of glaucomatous optic region, and the macula has been demonstrated in
neuropathy include visual field testing, nerve fibre patients with glaucoma using OCTA.20-22
layer (NFL), optic nerve head,4 ganglion cell layer
with inner plexiform layer (GCIPL), and ganglion cell PERG in Glaucoma
complex parameters analysis.5 Pattern electroretinogram
(PERG) is an objective measure of the central retinal Visual field (VF) remains the gold standard for
function that correlates with macular ganglion cell assessment of RGC's function, but it is a subjective
layer (GCL) thickness. Stress in the cellular and test and therefore, cannot always be relied upon due to
molecular environment that exceeds the survival its variability and lack of reproducibility.23
capacity of RGCs can lead to progressive damage to Furthermore, visual field detects the loss of function
ganglion cells and their fibres. This damage can of RGCs when these are irreversibly lost. It is known
induce retinal dysfunction, as revealed by flash that approximately 25 to 35% of the optic nerve axons
electroretinogram (FERG) or PERG recordings.6-9 are lost before the appearance of a visual field defect.24

Although increased intraocular pressure (IOP) is the Electroretinogram (ERG) is an objective measure that
predominant risk factor for retinal ganglion cell provides information about the function of retina. It is
death,10 reduced ocular perfusion has also been an electrical response generated by retinal cells when
proposed to play a role in the pathogenesis of exposed to various visual stimuli. This signal can vary
glaucoma.11,12 as we modify the characteristics of the visual stimuli
(i.e. luminance, contrast and pattern). ERG is well-
Earlier studies have measured ocular perfusion using known by ophthalmologists to diagnose a broad range

25

of retinal diseases such as retinitis pigmentosa and X- have lower amplitudes than those measured with
linked juvenile retinoschisis. However, it is not useful corneal electrodes.35 However, Porciatti and Ventura
for glaucoma diagnosis since it reflects the electrical demonstrated that by changing the characteristics of
activity of the outer retina, mainly bipolar cells and the stimulus using amplifiers and filters, they obtained
photoreceptors. a sufficiently strong amplitude and Signal to Noise
PERG is a mass potential that sums information Ratio to justify the use of skin electrodes. Therefore,
primarily from the electrical potentials of retinal they considered the PERGLA Protocol as a serious
ganglion cells.25-29 The PERG stimulus isolates the alternative in the clinical practice for early glaucoma
ganglion cell response by using a reversing (i.e., detection.34 Other studies confirmed this statement.36,37
contrast modulated) checkerboard or grating pattern
that carries no change in overall luminance over time Since 2004, it has been easier to obtain PERG
(space-averaged luminance). If the PERG response is measurements in a clinical setting using the PERGLA
measuring retinal ganglion cell activity, it should be protocol elaborated by Porciatti and Ventura.34 This
associated with the number of retinal ganglion cells. protocol was also studied by C. Bowd et al, to assess
Because retinal ganglion cell damage is the its repeatability for glaucoma detection by using the
underlying cause of glaucoma-related decreases in Glaid PERGLA device.38 Their results suggested that
visual sensitivity, the PERG should be useful for the PERGLA protocol using the Glaid was highly
detecting and monitoring this disease.30,31 repeatable in a population of healthy recruits and
It is well established that PERG is altered in glaucoma patients. Studies have reported a significant but
and is significantly reduced in subjects with ocular modest association between PERG amplitude and
hypertension, with standard automated perimetry neuroretinal rim area measured using confocal
being normal.32,33 There has been a lot of interest scanning laser ophthalmoscopy (CSLO) and RNFL
regarding PERG as an early glaucoma diagnostic tool, thickness measured using both optical coherence
but its application was limited to laboratories as it was tomography (OCT) and scanning laser polarimetry
not only time consuming to perform the test but also (SLP).39-43 These results suggest that PERG amplitude
required complex corneal electrodes positioning that is at least somewhat representative of ganglion cell
were invasive for the patient and difficult for the count.
ophthalmologist to perform. It was difficult to
interpret the results as well, since there was no specific It also is possible that weak cross-sectional
protocol or values. As a consequence, Porciatti and associations between PERG and structural
Ventura suggested a new paradigm for PERG known measurements might represent a temporal
as the PERGLA Protocol which uses skin electrodes decorrelation between functional and structural
taped on the lower eyelids, close to eyelashes, to damage.43
improve patient's comfort and facilitate PERG
acquisition and interpretation (Figure 1).34 Korth M et al. studied PERG in relation to aging and
glaucoma.44 The PERG responses showed an increase
Fig. 1: PERG waves and values using Diopsys®

It is known that PERG measured with skin electrodes

26

(P less than 0.001) in peak latency with increasing age the NFL distribution. The anatomic distribution and
and a decrease (P less than 0.001) in amplitude which unique morphologic characteristics help to
approximately parallels the loss of ganglion cells.44 distinguish the RPCs from other capillary plexuses
Many glaucoma eyes showed a loss of the normally within the retinal microcirculation.55 Despite the
present spatial tuning. A negative correlation (P less evidence that RPCs are critically related to RGC
than 0.001) was found between the size of the PERG function , the morphologic characteristics of RPCs are
and the cup/disc ratio and a positive correlation (P less not routinely used in clinical practice to evaluate
than 0.001) with the area of the neuroretinal rim of the glaucomatous progression.50,51,55 This may be because
optic disc.44 The PERG decreased (P less than 0.01) RPCs are not reliably visualized with fluorescein
with increasing visual field losses.44 angiography (FA),56 which is the mainstay imaging
OCTA in Glaucoma modality for clinically evaluating the retinal
Optical coherence tomography angiography (OCT-A) circulation. She X et al evaluated the reliability of
(Figure 2) is a relatively new, non-invasive imaging vessel density measurements in the peripapillary
technique that uses flow-based information to retina using OCTA and also analysed its correlation to
visualize the retinal and optic disc circulation.45 The RNFL thickness in healthy subjects. They concluded
morphologic characteristics of the foveal, perifoveal, that the vessel density measurements showed good
and peripapillary capillary networks have been repeatability and reproducibility by OCT-A in the
evaluated using speckle variance OCT-A and showed peripapillary retina, the vessel density was positively
that the topological and quantitative characteristics of related to RNFL thickness and negatively related to
these networks, as seen on OCT-A, are comparable to optic disc area and rim area.57
histologic representation. 46-49
The limited usefulness of traditional OCT in
Figure 2: OCTA scan of optic nerve head advanced glaucoma has been attributed to the floor
The nutritional demands of RGC axons are likely to effect, with the RNFL and GCC thicknesses showing
be partially satisfied by radial peripapillary capillaries little change with increasing severity of glaucoma.58
(RPCs)48,50-52 and structural changes to RPCs have been The vessel density measurements may be devoid of
implicated in the pathogenesis of Bjerrum scotoma53 the floor effect and may be better at detecting
and glaucoma.54 The RPCs represent a unique progression in advanced glaucoma. In late-stage
capillary plexus within the inner aspect of the NFL.50 glaucoma, particularly when VF mean deviation
They are largely restricted to the posterior pole of the (MD) is worse than -14 dB, OCTA-measured pfVD
human retina along specific retinal eccentricities (Peri-foveal vessel density) is a promising tool for
surrounding the optic nerve. Morphologically, this monitoring progression because it does not have a
capillary network displays minimal intercapillary detectable measurement floor.59 Lower baseline
anastomosis and shows a linear course in keeping with macular and optic nerve head (ONH) vessel density
are associated with a faster rate of RNFL progression
in mild to moderate glaucoma. Assessment of ONH
and macular vessel density may add significant
information to the evaluation of the risk of glaucoma
progression and prediction of rates of disease
worsening.60

Studies have evaluated the relationship between the
global vessel density measurement (average
peripapillary vessel density) and the global functional
measurements (mean deviation and mean sensitivity)
without evaluating the sectors separately.18,61 As the
vessel density around the disc varies in a similar

27

manner to the retinal nerve fibre layer (RNFL) Ophthalmology. 2013;120(3):535–543.
thickness, and because glaucoma preferentially
affects the poles of the ONH, a sectoral analysis of 5. BusselII,WollsteinG,SchumanJS. OCT for
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Address for correspondence :
59. Moghimi S, Bowd C, Zangwill LM et al.
Measurement Floors and Dynamic Ranges of Dr.Ankita Chaudhary
OCT and OCT Angiography in Glaucoma. MS, FICO, FRCS (Glasgow)
Ophthalmology. 2019 ;30858023 (Epub ahead of Vista healthcare Clinic, The Eye Pavilion
print) Sultan Business Centre, next to Lamcy Plaza
Oud Mehta, Dubai.
60. Moghimi S, Zangwill LM, Penteado RC et al. E-mail : ankita.phougat@gmail.com
Macular and Optic Nerve Head Vessel Density Phone : 9920988017
and Progressive Retinal Nerve Fibre Layer Loss in
Glaucoma. Ophthalmology. 2018;125(11):1720-1728.

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Ophthalmology. 2016;123:2498–2508.

Saving Sight in ROP

31

Managing ocular allergies in steroid responsive patients

Parveen Rewri MS

Department of Ophthalmology,
Maharaja Agrasen Medical College, Agroha (Hisar)

Abstract

Ocular allergies affect all age groups but more often younger population. Ocular manifestations are due to
immunoglobulin E (IgE) mediated immune response and itching and inflammation are hallmark of clinical
presentation. Severe or refractory cases of ocular allergy often require topical steroids to control inflammation
and arrest disease process. A variable rise in intra-ocular pressure (IOP) is known to occur with usage of steroids.
Control of inflammation in a steroid responder is always challenging and need a modified, balanced strategy.

Keywords: Ocular allergy, Steroid response, Glaucoma.

Introduction Steroid response, complications and their

The practice of medicine is capable of rendering noble management
Ocular allergies affects 15-40% of the population One most unwanted adverse effect of topical steroid
depending upon climatic and weather conditions.1 usage is rise in intra-ocular pressure, often labelled as
The condition is more prevalent among residents of steroid response. In a clinical setting, when patient is
hot, humid tropical climate, and incidence increases steroid responder, management of ocular allergy
in seasons of spring and summer.1 Ocular allergy is an becomes challenging. Such a clinical scenario
inclusive term that encompasses diverse conditions demands relief of symptoms and control of
including seasonal allergic conjunctivitis (SAC), inflammation while keeping IOP under control.
perennial allergic conjunctivitis (PAC), vernal Incidence of steroid induced glaucoma (SIG) among
keratoconjunctivitis (VKC), and atopic keratocongiuntivitis children with ocular allergies has increased over the
(AKC). past years.3 Children have more intense steroid
response than adults, and more so in children with
Ocular Allergy VKC.4
Ocular manifestations are due to immunoglobulin E Steroid response is influenced by presence of risk
(IgE) mediated immune response to allergen exposure factors for steroid responsiveness, type of steroid and
in sensitized individuals. Itching is hallmark of ocular duration of steroid therapy. In approximately 5% of
allergy, often associated with tearing, conjunctival population, daily administration of topical
hyperemia, chemosis, and conjunctival and lid corticosteroids for 2-6 week, results in increase in
swelling.2 Treatment options for ocular allergy are IOP>15 mmHg. Such a response is known as high
intended to reduce inflammation and provide steroid responsiveness.5 In another 30% population, a
symptomatic relief from itching. Itching is managed moderative steroid responsiveness, an increase of 6-
with anti-histaminic and dual mast cell stabilizer and 15 mmHg of IOP, takes place.5A rise of IOP >10
anti-histaminic drugs. Combination drug containing mmHg above baseline is considered clinically
vasoconstrictor, anti-histaminic and non-steroidal significant.6 There are no known biomarkers for
anti-inflammatory ingredients, helps to control both steroid responsiveness. Hence, identifying the
itching and inflammation, in mild to moderate cases patients who are at risk of steroid response should be
of ocular allergy. Severe or refractory cases of ocular first step in management of ocular allergies requiring
allergy often require topical steroids to control initiation of steroid therapy. Risk of steroid response
inflammation and arrest disease process. These are is high among patients of primary open angle
most effective topical drugs to control both acute and glaucoma (POAG), their siblings or offspring, those
chronic forms of ocular allergy.

32

with high myopia, history of atopy, connective recommended for children below 2 years of age.
tissue disorders especially rheumatoid arthritis, Since, risk of developing steroid induced glaucoma
diabetes mellitus, very young children (<10 years), (SIG) is higher in unmonitored/unsupervised
pigment dispersion syndrome and traumatic angle patients, periodic monitoring of IOP is desirable.
recession.7-11 It should be routine practice to include Follow up visits may be scheduled based on IOP,
baseline IOP and central corneal thickness (CCT) in health of optic nerve, intensity of steroid therapy, and
clinical examination of ocular allergy patient IOP response. In patients with baseline IOP in upper
before initiating any therapy. teens or early twenties and healthy optic nerve,
The steroids must be prescribed with cautions in weekly follow up would be sufficient. In patients with
patients with risk factors for steroid response as they IOP in upper twenties or more or those with pre-
are likely to have heightened steroid response. There existing optic nerve damage, should be seen more
is significant difference among commercially frequently, may be twice or thrice a week.
available topical steroids in their propensity to cause Steroid response is reversible in most cases and IOP
IOP elevation. Almost all older generation topical returns to normal within 2-4 after cessation of topical
corticosteroids like dexamethasone, betamethasone, therapy. The reversal of IOP response on cessation of
prednisolone and few newer generation topical therapy depends upon duration of IOP use. In cases
steroids like difluprednate are more likely to result in with more chronic use beyond 18 months, IOP
clinically significant IOP elevation compared to soft reversal may take longer time.In approximately 4% of
steroids like fluorometholone, rimexolone, and patients secondary SIG ensue despite withdrawal of
loteprednol etabonate. It may be prudent to choose steroids.14
from among soft steroids in patients with risk factor(s) A subset of patients with severe ocular allergy would
steroid response. require continuation of steroid therapy despite steroid
Best strategies would be to avoid use of topical response. Steroid may need to be restarted in patients
steroids in patients likely to have steroid response; and in whom ocular allergy worsen after steroid
to abort steroid therapy in cases where IOP is raised to withdrawal or remains non-responsive to topical
clinically significant level (>10 mmHg). However, steroid sparing therapy. In such patients, elevated IOP
this might not be possible clinically in all cases. In may be controlled with topical or oral anti-glaucoma
severe cases, to treat acute stage or flare-ups, topical medications (AGM). All topical AGM have intrinsic
steroids, preferably soft ones, may be used for short potential to cause ocular allergy. The choice of AGM
course (up to 2 weeks). Patients should be tapered off in patient of ocular allergy may be difficult. Ocular
rapidly, and substituted with topical non-steroidal surface toxicity is much more likely with preservative
anti-inflammatory drugs (NSAIDs) or steroid sparing containing topical AGMs. It may be preferable to use
immunosuppressant drugs (SSISDs).A range of preservative free topical anti-glaucoma medications.
steroid-sparing drugs, including topical non-steroidal Conjunctival hyperaemia is more common with
anti-inflammatory drugs (NSAID) and topical prostaglandin analogues. These drugs may be avoided
calcineurin inhibitors, has been shown effective in as first line therapy to control IOP. In cases requiring
managing ocular allergies.12 Topical ocular more than one drug to control IOP, fixed drug
preparations of cyclosporine A (0.05-2%) and combinations should be preferred to keep
tacrolimus(0.03-0.1%) both has been found to be preservative dose to minimum. Other possible
effective in controlling VKC. Both of these drugs have approaches to manage sustained elevated IOP are oral
also been found effective in steroid refractory VKC.13 carbonic anhydrase inhibitors, selective laser
It would be prudent to use tacrolimus as a second line trabeculoplasty (SLT) or micropulse diode laser
treatment after cyclosporine A. It's because US Food trabeculoplasty (MPDLT). The effectiveness of SLT
and Drug Administration warns on use of tacrolimus in SIG has been established. Incisional surgeries like
ointment in treatment of atopic dermatitis for its trabeculectomy or glaucoma drainage device are
potential to cause cancer. Tacrolimus is not

33

reserved for medically uncontrolled or intractable Allergy Immunol. 2012;30:177–184.
glaucoma. 13. Addis H, Jeng BH. Vernal keratoconjunctivitis.

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14. Tranos P, Bhar G, Little B. Postoperative
conjunctivitis: a comprehensive review of the intraocular pressure spikes: the need to treat. Eye
literature. Ital J Pediatr. 2013;39:18. Published (Lond.).2004;18:673-679.
2013 Mar 14. doi:10.1186/1824-7288-39-18.
2. Chigbu DI. The pathophysiology of ocular Address for correspondence:
allergy: A review. Cont Lens Anterior Eye.
2009;32:3-15. Dr. Parveen Rewri
3. Gupta S, Shah P, Grewal S, Chaurasia AK, Gupta Associate Professor, Deptt. Of Ophthalmology,
V. Steroid-induced glaucoma and childhood Maharaja Agrasen Medical College, Agroha (Hisar)
blindness. Br J Ophthalmol. 2015;99:1454-14560. Glaucoma Services, Haryana 125047
4. Addis H, Jeng BH. Vernal keratoconjunctivitis. E-mail : drparveenrewri@gmail.com
Clin Ophthalmol. 2018;12:119–123. Published Mobile: 9991026462
2018 Jan 11. doi:10.2147/OPTH.S129552.
5. Armaly MF. Effects of corticosteroids on
intraocular pressure and fluid dynamics. Arch
Ophthalmol. 1963;70:492-499.
6. Roberti G, Oddone F, Agnifili L, et al. Steroid
induced glaucoma: epidemiology,
pathophysiology and clinical management. Sur
Ophthalmol. 2020 [Ahead of print]doi:
https://doi.org/10.1016/j.survophthal.2020.01.0
02
7. Becker B, Chevrette L. Topical corticosteroids
testing in glaucoma siblings. Arch Ophthalmol.
1966;76:484-487.
8. Becker B, Hahnka L. Topical corticosteroids and
heredity in primary open angle glaucoma. Am J
Ophthalmol 1964;57:543-551.
9. Becker B, Podos SM.Krukenberg's spindle and
primary open angle glaucoma. Arch Ophthalmol.
1966;76:635-639.
10. Spaeth GL. Traumatic hyphema, angle recession,
dexamethasone hypertension and glaucoma.
Arch Ophthalmol. 1967;78:714-721.
11. Podos SM, Becker B, Morton WR. High myopia
and primary open-angle glaucoma. Am J
Ophthalmol. 1966;62:1038-1043.
12. Labcharoenwongs P, Jirapongsananuruk O,
Visitsunthorn N, Kosrirukvongs P, Saengin P,
Vichyanond P. A double-masked comparison of
0.1% tacrolimus ointment and 2% cyclosporine
eye drops in the treatment of vernal
keratoconjunctivitis in children. Asian Pac J

34

Biosimilar vs innovator : our experience

Salil Gupta MS, Ex Fellow Sankara Nethralya,
Himanshu Goyal MS, Ex FLVPEI

Saraswati Nethralaya, Karnal

Abstract

Aim and Objective: To evaluate the safety and efficacy of intravitreal ranibizumab – Accentrix and its biosimilar
Razumab for the treatment of diabetic macular edema (DME).Methods: A prospective study of 90 days was
performed on consented patients with DME. Twenty subjects were given Accentrix and 20 Razumab injection at
baseline. Snellen visual acuity assessment and optical coherence tomography imaging were done at day 0 and
30th day respectively. Outcome measures included changes in best corrected visual acuity (BCVA) and central
macular thickness (CMT) and intraocular pressure (IOP).Results: In Razumab, CMT at the end of 30 days was
reduced to 298.60 µ from 433.10 µ resulting in 31.05% reduction, whereas, in accentrix, group, CMT was reduced
to 302.70 from 433.10 µ making a reduction of 29.37%. The comparison was insignificant. The BCVA post
injection was significantly improved in both the groups. There were no serious drug related ocular or systemic
adverse events.Conclusion: Short term results suggest that biosimilar ranibizumab could become a safe, low cost
therapy for macular diseases although the long term safety and efficacy remains unknown.

Keywords: Intravitreal Anti VEGF Injection, Accentrix, Razumab, Diabetic macular edema.

Introduction Razumab is approved by the Drug Controller General
of India. A biosimilar is a biological medicine which
The most common ocular diseases that cause visual is similar to an existing biological medicine. The
loss are related to the pathological retinal active substance of a biosimilar and its reference
neovascularization and edema. Diabetic retinopathy medicine have the similar biological substance,
(DR) (proliferative DR and diabetic macular edema however they differ in complex nature and methods of
[DME]), neovascular age related macular production.4
degeneration (nAMD), and retinal vein occlusion The Razumab is biosimilar of ranibizumab like
(RVO) are the leading causes of blindness.1 Lucentis but less expensive and affordable than later.
Drugs that inhibit the actions of VEGF have become This study is designed to assess the efficacy and safety
the standard of care for several chorioretinal vascular of this newly approved alternative in India.
conditions including nAMD, DME, and macular Material and Methods
edema due to RVO. 2 This study was carried out at Saraswati Nethralaya,
Developed countries like USA, UK and European Karnal on 40 patients who have given the informed
union have approved many anti-VEGF drugs like and written consent. For this patients included were
pegaptanib (Macugen; Eyetech, New York, USA), those who were diagnosed with DME. Subjects who
ranibizumab (Lucentis; Genentech, Basel, had signs of ocular infection, previous vitrectomy and
Switzerland) and aflibercept (Eylea; Regeneron, a history of cerebrovascular accident or myocardial
Tarrytown) for many of these conditions which are infarction were excluded from this study.
costly and out of reach for patients of devloping and As part of this study, a comprehensive ocular
poor countries. A less expensive alternative like off- investigations were done like measurement of BCVA
label bevacizumab (Avastin; Genentech/Roche) is the using the standardized Snellen visual acuity charts,
most commonly used anti-VEGF drug worldwide. 3 optical coherence tomography (OCT) and IOP.
Intravitreal ranibizumab (Accentrix/Lucentis) has For this comparative study subjects were divided in 2
emerged as an effective treatment of retinal vascular groups of 20 each based on the Intravitreal injection
diseases, but its high cost make it unaffordable to most given. First group was given the Razumab biosimilar
of patients in developing countries like India. and efficacy and safety measured on parameters
The biosimilar of ranibizumab developed in India is

35

which were taken before and after the injection: CMT, Table 3 : Repeat injections
IOP, BCVA, repeat injection and any complication
post the injection. Repeat Injection Razumab Accentrix
Second group was administered with the Accentrix Yes 3 2
and above mentioned parameters were recorded No 17 18
before and after the injection. Total 20 20
All the data analysis was performed using IBM SPSS
ver. 20 software. Descriptive analysis was performed The BCVA post injection was significantly improved
first. Statistical analysis and data recording was done both with Razumab as well as Accentrix. No side
using the MS excel. Quatitative data is expressed as effects or post injection complications were reported
mean and standard deviation. Categorical data is by any of the subject out of sample of 40 patients.
expressed as percentage. Student t test was applied to
compare the mean and categorical data is compared Discussion
using chi square test. P value of <0.05 is considered as Ranibizumab binds to and inhibits the biologic
significant. activity of human VEGF-A. It binds to the receptor
binding site of active forms of VEGF-A, including the
Results biologically active, cleaved form of this molecule,
There was significant reduction in CMT after VEGF110. VEGF-A is thought to contribute to
pathophysiology of nAMD, macular edema
injection of Razumab as well as Accentrix. following RVO, DR, and DME. The binding of
ranibizumab to VEGF-A prevents the interaction of
Table 1 : CMT before and after the injection VEGF-A with its receptors (VEGFR1 and VEGFR2)
on the surface of endothelial cells, reducing
CMT Razumab Accentrix endothelial cell proliferation, vascular leakage, and
Mean SD new blood vessel formation.4
Mean SD 428.60 76.39 The high cost of pharmaceuticals, especially
biologics, has become an important issue in the battle
Pre Injection 433.10 61.01 to control health-care costs in such diseases.
Biologicals are derived from living cells or organisms
Post Injection 298.60 70.718 302.70 66.13 and consist of relatively large and often highly
complex molecular entities that may be difficult to
P value <0.001 0.042 fully characterize. 5 Biosimilars are highly similar to
already approved innovator or “reference” biologics
CMT; central macular thickness, SD; standard in terms of structure, efficacy, safety, and quality.6
deviation, P value of <0.05 is considered as Due to low cost biosimilars have the potential to
significant reduce health-care costs compare to the reference
biologics. The ranibizumab (Lucentis; Genentech,) is
IOP in both groups of subjects did not change an USA govt approved biologic for the treatment of
drastically (p-value 0.32) before the injection and retinal vascular disorders but not accessible due to
insignificant after the injection (p value =0.55). high cost and the biosimilar ranibizumab (Razumab;
Intas Pharmaceuticals) is the first ophthalmic
Table 2 : IOP before and after injection biosimilar which has been developed in India based
on a more extensive head-to-head comparison with
IOP Razumab Accentrix the reference product (Lucentis), to ensure close
Average SD Average SD resemblance in physicochemical and biologic
Pre Injection 15 2.38 14.65 1.98 characteristics, safety, and efficacy also it is more
Post Injection 15.65 2.37 14.85 2.033
P value 0.563 0.462

SD; standard deviation, P value of <0.05 is considered
as significant

36

accessible to the patients due to its low price. 7 implementation. Pharmacy and therapeutics.
In a similar study by Sameera et al 2016 also 2013;38:624-627.
concluded that the Razumab is a safe, effective and 7. Korobelnik JF, Holz FG, Roider J, Ogura Y,
inexpensive alternative for ocular retinal disease Simader C, Schmidt-Erfurth U, et al.
treatment.8 Intravitrealaflibercept injection for macular
edema resulting from central retinal vein
Conclusion occlusion: One-year results of the phase 3 galileo
We found the biosimilar intravitreal ranibizumab was study. Ophthalmology. 2014;121:202-208.
matching with the reference product in both safety 8. Sameera VV, Apoorva AG, Shrinivas J,
and efficacy with desirable quality attributes in India. Guruprasad AS. Safety and efficacy of Razumab
The initial data show good clinical response though – The new biosimilar in India: Our experience.
the study was only for a short period of 3 months. The Kerala J Ophthalmol. 2016; 28 (3): 180-185.
pilot study in 40 eyes shows no evidence of acute
adverse reaction and safety concerns. The drug was Address for correspondence:
tolerated over a month with improvements in BCVA
and CMT. Short term results suggest that biosimilar Dr. Salil Gupta
ranibizumab (Razumab) could become a safe, low Director, Saraswati Nethralaya, Karnal.
cost therapy for macular diseases. Further E-mail : salilmona@yahoo.com
investigations into its long term safety and efficacy Mobile: 9996066555
are warranted.

References
1. Brand CS. Management of retinal vascular

diseases: A patient-centric approach. Eye (Lond.)
2012;26 (Suppl 2):S1-16.
2. Rofagha S, Bhisitkul RB, Boyer DS, Sadda SR,
Zhang K; SEVEN-UP Study Group. Seven-year
outcomes in ranibizumab-treated patients in anchor,
marina, and horizon: A multicenter cohort study
(SEVEN-UP). Ophthalmology. 2013;120:2292-
2299.
3. Korobelnik JF, Do DV, Schmidt-Erfurth U, Boyer
DS, Holz FG, Heier JS, et al. Intravitrealaflibercept
for diabetic macular edema. Ophthalmology.
2014;121:2247-2254.
4. European Medicine Agency. EMA/837805/2011.
Accessed on 10 June, 2019.
5. Nguyen QD, Shah SM, Khwaja AA, Channa R,
Hatef E, Do DV, et al. Two-year outcomes of the
ranibizumab for edema of the mAcula in diabetes
(READ-2) study. Ophthalmology. 2010;117:2146-
2151.
6. Ventola CL. The role of pharmacogenomic
biomarkers in predicting and improving drug
response: Part 2: Challenges impeding clinical

37

Molluscum contagiosum of the eyelid - an overview

Yash Pal Ranta MS, R.L. Sharma MS

Department of Ophthalmology, IGMC Shimla

Abstract

Molluscum Contagiosum of eyelid is a rare viral infection caused by a DNA pox virus. It is a recognised
complication of Acquired Immune Deficiency Syndrome. Clinical diagnosis is made by its typical presentation of
umbilicated lesions which can be confirmed by PCR and excisional biopsy. The disease may be self-limiting or
may require topical application of Retinion cream. Persistent disease requires surgical intervention.

Keywords: Molluscum Contagiosum,AIDS, cryosurgery,Retinoin,Tacrolimus.

Introduction items such as clothing or towels. The virus commonly
spreads through skin-to-skin contact which includes
Molluscum Contagiosum is a rare viral infection sexual contact or touching or scratching the bumps
caused by a DNA poxvirus called the molluscum and then touching the skin.
contagiosum virus (MCV). There are four types of The portal of entry of the riders into the body is
MCV, MCV-1 to -4; Molluscum contagiosum virus- usually through some form of break in the skin. This
1(MCV-1) to MCV-4) replicating in the cytoplasm of occurs through direct skin to skin contact which
host cell especially in the epidermal cells.1-3 This includes sexual contact or touching or scratching the
common viral disease has a higher incidence in bumps and then touching the skin. The virus can
children, sexually active adults, and those who are spread from one part of the body to another or to other
immunodeficient, and the infection is most common people and can therefore be seen in individuals who
in children aged one to ten years old. MCV-1 is the share showers or athletes who share equipment in the
most prevalent in small children, and MCV-2 is seen gymnasium. Having low levels of immunity such as in
usually in adults and often sexually transmitted and the case of HIV virus infections can also make an
cause majority of infection in HIV patients.2 MC can individual prone to developing Molluscum
affect any area of the skin but is most common on the Contagiosum. In such individuals, the lesions are a lot
trunk of the body, arms, and legs.MCV has no animal more widespread. In children, the condition occurs
reservoir and exclusive infect humans. It is due to sharing of towels and sponges. An association
characterised with the presence of small elevated between school swimming pool use and molluscum
lesions called papules. These papules have a waxy contagiosum infection has also been reported. 4,5
surface and are seen on various parts the body such as MC is a recognized ocular complication of acquired
the face, trunk, arms and legs. It can also affect the immune deficiency syndrome2-6 and has been reported
armpits but does not involve the palms. It has also in patients undergoing systemic steroid treatment for
been found to affect the eyelids. atopic dermatitis7,8 and arthritis.9 Studies have also
Bateman first described the disease in 1817, and shown the development of Molluscum Contagiosum
Paterson demonstrated its infectious nature in 1841. affecting the eyelids of both eyes following treatment
In 1905, Juliusburg proved its viral nature. Infection of rheumatoid arthritis with specialist drugs such as
follows contact with infected persons or contaminated methotrexate.9 The eyelid is the most common site of
objects, but the extent of epidermal injury necessary is ocular lesions, although conjunctival lesions have
unknown. Lesions may spread by autoinoculation. been reported.3,8,9 Intraocular MC following
Pathogenesis corneoscleral laceration has also been confirmed
Molluscum contagiosum is caused by a viral
infection. It is spread through direct contact or shared

38

histologically.10 Chronic conjunctivitis or excisional biopsy. The central waxy core contains the
keratoconjunctivitis can be associated with eyelid virus. Histologically, molluscum contagiosum is
lesions.11,12 Keratoconjunctivitis associated with MC characterized by inclusion bodies (molluscum
is generally chronic and features marked follicular bodies) in the epidermis, above the stratum basale.
conjunctivitis along with punctate keratopathy and These bodies can be stained using specific stains to
epithelial or subepithelial infiltrates.11,13,14 Case reports help identify them under a microscope, which consist
have detailed molluscum contagiosum eruptions in of large cells with abundant granular eosinophilic
areas that were treated with tacrolimus 0.1% cytoplasm (accumulated virions) and a small
(Protopic).15,16,17 peripheral nucleus.19 Following infection, cellular
Approximately 122 million people were affected proliferation produces lobulated epidermal growths
worldwide by molluscum contagiosum as of 2010 that compress epidermal papillae, while fibrous septa
(1.8% of the population).18 between the lobules produce pear-shaped clumps
with the apex upwards. The basal layer remains intact.
Clinical features Cells at the core of the lesion show the greatest
Molluscum Contagiosum are small papules with a distortion and are ultimately destroyed, resulting in
waxy surface, flesh-colored, dome-shaped and pearly large hyaline bodies (ie, molluscum bodies,
in appearance (Figure 1). They are often 2–5 Henderson-Paterson bodies) containing cytoplasmic
millimeters (rarely up to 1.5 cm in the case of a giant masses of virus material. These bodies are present in
molluscus )in diameter with a umbilications (dimpled large numbers and appear as a white depression at the
center) that contain a waxy, curdlike core. They are center of fully developed lesions.
generally not painful, but they could itch or become
irritated. In about 10% of the cases, eczema develops Treatment
around the lesions. They could occasionally be Most cases of molluscum contagiosum will clear up
complicated by secondary bacterial infections. In naturally within two years (usually within nine
some cases the dimpled section could bleed once or months). So long as the skin growths are present, there
twice. They could be clearly evident on the body is a possibility of transmitting the infection to another
especially on the eyelids. Typically, scratching the person. When the growths are gone, the possibility of
lesions can make them worse as more and more spreading the infection is ended.20
lesions form along the line of scratching. This is a
typical phenomenon called as Koebner phenomenon. Medication
In the Koebner phenomenon, new lesions develop For mild cases, over – the –counter wart medicines,
along a line of trauma and the etiology of the such as salicylic acid21 may shorten infection
underlying condition is unknown. Psoriasis and lichen duration. Daily topical application of tretinion cream
planus are examples of skin conditions that may also trigger resolution.22 These treatments
commonly koebnerize. Autoinoculation is different require several months for the infection to clear, and
from the Koebner phenomenon, which is also called are often associated with intense inflammation and
an isomorphic response. Patients with poor immune possibly discomfort.
levels tend to have multiple lesions all over the body. Studies have found cantharidin to be an effective and
The involvement of the eyelids and the face is safe treatment for removing molluscum
commonly seen in children whereas the involvement contagiosum.23 This medication is usually well-
of the groin area is seen in adults. Associated with tolerated though mild side effects such as pain or
molluscum contagiosum are other skin conditions blistering are common.23 There is no high-quality
such as atopic dermatitis and eczema. evidence for cimetidine.24 However, oral cimetidine
has been used as alternative treatment for pediatric
Diagnosis population as it is more difficult to use more invasive
A diagnosis of molluscum contagiosum can be made and discomforting application. Medical for the
by tests such as polymerase chain reaction and treatment of molluscum Contagiosum does not

39

appear to be effective. 5. Connell CO, Oranje A, Van Gysel D, Silverberg
NB. Congenital molluscum contagiosum:
Surgery report of four cases and review of the literature.
Surgical treatments include cryosurgery, in which Pediatr Dermatol. 2008 Sep-Oct. 25(5):553-556.
liquid nitrogen is used to freeze and destroy lesion, as
well as scraping them off with a curette (Figure 2). 6. Schornack MM, Siemsen DW, Bradley EA,
Application of liquid nitrogen may cause burning or Salomao DR, Lee HB. Ocular manifestations of
stinging at the treated site, which may persist for a few molluscum contagiosum. Clin Exp Optom.
minutes after the treatment. With liquid nitrogen, a 2006;89:390-393.
blister may form at the treatment site, but it will
slough off in two to four weeks. Cryosurgery and 7. Vardhan P, Goel S, Goyal G, Kumar N. Solitary
curette scraping can be painful procedures and can giant molluscum contagiosum presenting as lid
result in residual scarring.25 tumor in an immunocompetant child. Ind J
Ophthalmol. 2010;58:236-238.
Fig. 1 Fig. 2
Molluscum Contagiosum After Surgical Removal 8. Cursiefen C, Grunke M, Dechant C, Antoni C,
Junemann A, Holbach LM. Multiple Bilateral
Laser Eyelid Molluscum Contagiosum Lesions
A 2014 systematic review of case reports and case Associated With TNF alpha-antibody and
Methotrexate Therapy. Am J Ophthalmol.
series concluded that the limited available data 2002;134:270-271.

suggest pulsed dye laser therapy is a safe and effective 9. Scheinfeld N. Treatment of molluscum
contagiosum: A brief review and discussion of a
treatment for molluscum contagiosum and is case successfully treated with adapelene.
generally well-tolerated by children.25 Side effects Dermatology Online J. 2007;13:15.

seen with pulsed dye laser therapy included mild 10. Postlethwaite R, Watt JA, Hawley TG, Simpson
T, Adam H. Features of molluscum
temporary pain at the site of therapy, bruising (lasting contagiosum in the north-east of Scotland and
Fijian village settlements. J Hyg (Lond.).
up to 2–3 weeks), and temporary discoloration of the 1967;65:281-291.
treated skin (as long as 1–6 months).25 No cases of
permanent scarring have been reported.25 11. Kakourou T, Zachariades A, Anastasiou T,
Architectonidou E, Georgala S,Theodoridou M.
References Molluscum contagiosum in Greek children: a
1. Charteris DG, Bonshek RE, Tullo AB. case series. Int J Dermatol. 2005;44:221-223.

Ophthalmic molluscum contagiosum: clinical 12. Van der Wouden JC, van der Sande R, van
Suijlekom-Smit LW, Berger M,Butler CC,
and immunopathological features. Br J Koning S. Interventions for cutaneous
molluscum contagiosum.Cochrane Database
Ophthalmol. 1995;79:476-481. Syst Rev. 2009;CD004767.
2. Laxmisha C,Thappa DM, Jaisankar TJ. Clinical
13. Hanna D, Hatami A, Powell J, et al. A
profile of molluscum contagiosum in children prospective randomized trial comparing the
efficacy and adverse effects of four recognized
versus adults. Dermatology Online J. 2003;9:1. treatments of molluscum contagiosum in
3. Highet AS. Molluscum contagiosum. Arch Dis children. Pediatr Dermatol. 2006;23:574-579.

Child. 1992;67:1248-1249. 14. Weller R, O'Callaghan CJ, MacSween RM,
4. C h o o n g K Y, R o b e r t s L J . M o l l u s c u m White MI. Scarring in molluscum contagiosum:
comparison of physical expression and phenol
contagiosum, swimming and bathing: a clinical ablation. BMJ 1999;319:1540.
analysis.Australas J Dermatol. 1999 May.
15. Ahn BK, Kim BD, Lee SJ, Lee SH. Molluscum
40(2):89-92.

40

contagiosum infection during the treatment of Contagiosum".Adolesc Med. 7 (1): 57–62.
vitiligo with tacrolimus ointment. J Am Acad 23. Torbeck R, Pan M, DeMoll E, Levitt J (June
Dermatol. 2005 Mar. 52(3 Pt 1):532-533.
16. Fery-Blanco C, Pelletier F, Humbert P, Aubin F. 2014). “ Cantharidin: a comprehensive review of
[Disseminated molluscum contagiosum during the clinical literature” Dermatology online
topical treatment of atopic dermatitis with journal (Review). 20 (6).PIMD 24945640.
tacrolimus: efficacy of cidofovir]. Ann 24. Scheinfeld N (March 2003). “Cimetidine: a
DermatolVenereol. 2007May.134(5 Pt1):457-459. review of recent developments and reports in
17. Wilson LM, Reid CM. Molluscum contagiosum cutaneous medicine”. Dermatol. Online J.9
in atopic dermatitis treated with 0.1% (2):4.PMID 12639457.
tacrolimus ointment. Australas J Dermatol. 25. Griffith, RD; Yazdani Abyaneh, MA; Falto-
2004Aug. 45(3):184-185. Aizpurua, L; Nouri, K (November 2014).
18. Vos, Theo; Flaxman, Abraham D; Naghavi, "Pulsed dye laser therapy for molluscum
Mohsen; Lozano, Rafael; Michaud, Catherine; contagiosum: a systematic review". Journal of
Ezzati,Majid; Shibuya, Kenji; Salomonn, Joshua Drugs in Dermatology (Review). 13 (11):
A; Abdalla, Safa; Aboyans, Victor; Abraham, 1349–52. PMID 25607701.
Jerry;Ackerman, Ilana; Aggarwal, Rakesh; Ahn, 26. Brown, M; Paulson, C; Henry, SL (Oct 15, 2009).
StephanieY;Ali, Mohammed K;AlMazroa, "Treatment for anogenital molluscum
Mohammad A; Alvarado, Miriam; Anderson, H contagiosum". American family physician. 80 (8):
Ross; Anderson, Laurie M; Andrews, Kathryn 864. PMID 19835348.
G; Atkinson, Charles; Baddour, Larry M;
Bahalim, Adil N; Barker-Collo, Suzanne; Address for correspondence:
Barrero, Lope H; Bartels, David H; Basanez, Dr.Yashpal Ranta
Maria-Gloria; Baxter,Amanda; Bell, Michelle L; Senior Resident, IGMC, Shimla.
Benjamin, Emelia J (Dec 15, 2012). "Years E-mail : ranta1966@gmail.com
lived with disability (YLDs) for 1160 sequelae of Mobile : 9418464201
289 diseases and injuries 1990-2010: a
systematic analysis for the Global Burden of New Normal?
Disease Study 2010". Lancet. 380 (9859):
2163–96. PMID 23245607.doi:10.1016/S0140-
6736(12)61729-2.
19. Chen, X; Anstey, AV; Bugert, JJ (October 2013).
"Molluscum contagiosum virus infection". Lancet
Infectious Diseases. 13 (10): 877–88.
doi:10.1016/S1473-3099(13)70109-9.
20. Frequently Asked Question: United States
Centers for Disease Control and Prevention,
Retrieved 2008-12-08.
21. Schmitt, Jochen; Diepgen, Thomas L. (2008). “
Molluscum contagiosum” (PDF). In Berthold
Rzany; Williams, Hywel; Bigby, Michael E.;
Diepgen, Thomas L.; Herxheimer, Andrew;
Luigi Naldi. Evidence-Based Dermatology
(PDF). Evidence-based Medicine. London: BMJ
Books. ISBN 1-4051-4518-8.
22. Credo, BV; Dyment, PG (1996). "Molluscum

41

Regional anaesthesia in eye

Sakshi Lochab MBBS, Manisha Nada MS,DNB, Jitender Phogat MS,
Aakash Sharma MBBS, Monika Dahiya MS, Manoj P, MBBS

Regional Institute of Ophthalmology, PGIMS, Rohtak

Abstract

It is very important for an ophthalmologic practitioner to have the skill to anaesthetize the eye safely and
effectively using various techniques. The type of anaesthetic technique should be based on the specific
requirements of the patient, surgeon's preferences, the nature and extent of eye surgery. This article provides an
introduction to safe administration of ophthalmic anaesthesia.

Keywords: Regional ophthalmic anaesthesia, topical anaesthesia, orbital spaces.

Introduction optic canal transmits the optic nerve and ophthalmic
artery. Superior orbital fissure is comma shaped
Anaesthesia and akinesia are two prerequisites for aperture in the orbital cavity and is bounded by greater
ophthalmic surgery. Most of the ophthalmic surgeries and lesser wings of sphenoid.
can be performed under regional or topical
anaesthesia. Moreover local anaesthetic techniques Fig.1:Structures entering the apex of orbital cavity
are also indicated in different subset of ophthalologic Surgical spaces of orbit
surgeries where general anaesthesia may not be There are 4 potential surgical spaces in eye (Figure 2).
appropriate. Majority of patients presenting for The subperiosteal space- is a potential space between
ophthalmic surgery are elderly and may be having the periorbita and the orbital bones and is limited
pre-existing medical problems. Regional anaesthesia anteriorly by the strong adhesions of periorbita and
is safe in such situations and usually associated with orbital bones.
lower morbidity than general anaesthesia.1,2 The subtenon's space- is potential space around the
Akinesia of the eye can be produced by injecting local eyeball between the tenon's and the sclera.
anaesthetic in or around the surgical spaces via a The peripheral space- is bounded peripherally by
needle or by using a blunt cannula to instill local periorbita, internally by the four recti with their
anaesthetic under the Tenon's capsule.3 Topical intermuscular septa, anteriorly by the septum orbitale
application of local anaesthetic drops or gel can be and posteriorly it merges with the central space.
done to produce anaesthesia without motor blockade.3 The central space- is bounded anteriorly by the tenon's
capsule, peripherally by the extraocular muscles and
Anatomy their septa.
Orbits are quadrangular truncated pyramidal- shaped
cavities bounded by anterior cranial fossa superiorly,
nasal cavity & ethmoidal air sinuses medially and
maxillary sinus inferiorly. Each orbit measures 30cc
in volume and is made up of 7 bones namely:
Frontal, Sphenoid, Ethmoidal, Maxillary, Palatine,
Lacrimal and Zygomatic bone. The roof is horizontal
and the medial wall sagittal but the lateral wall is at a
45 degree angle and the floor rises slightly.4 The apex
and superomedial parts of the orbit are the most
vascular areas, which is why needle penetration in
these areas should be avoided.5 The apex contains the
optic canal and superior orbital fissure (Figure 1). The

42

Fig.2: The surgical spaces of the orbit: ciliary nerves.7 It has been superseded by newer
(A) Axial view. (B) Coronal view techniques with lesser side effects and more safety.
Technique:
Anesthetic solution
Local anesthetics (LAs) agents are weak bases that act l Take a 23G needle with a syringe filled with
by crossing the nerve membrane in unionized form 2- 3.5 ml of anesthetic solution.
and become ionized intracellularly and then block the
action potential by binding to intracellular sodium l Palpate the lower orbital rim and slowly pass
channels. Most commonly used anesthetic agents are the needle through the skin or the
lignocaine and bupivacaine for injection. The choice conjunctiva at the junction of its lateral one
of agent depends upon requirements for speed of third and middle two thirds. One should keep
onset, duration of block and desired potency. the bevel of the needle pointing upwards
towards the globe. The needle is then passed
l Lignocaine 2% is the most popular agent for straight back below the eye for 15 mm and it
nerve blocks. It has a rapid onset of action should be parallel to the floor of the orbit and
and its effect will usually last for an hour. For angled down.
prolonged procedures such as vitreoretinal
surgery Bupivacaine 0.5% is used as its l Change the direction of the needle so that it
action lasts for three hours or even longer. faces upwards and inwards and slowly inject
the anesthetic agent.
l Hyaluronidase can be used in a concentration
of approximately 50 units/ml. Hyaluronidase l One should look for drooping of lids and
is used to increase the effectiveness of a dilation of pupils.
block by facilitating the spread of lignocaine
or bupivacaine through the tissues. l Close the eyes with a pad of cotton and apply
firm pressure for 5-10 minutes.
l We can use adrenaline to slow the absorption
of anesthetic agents into the systemic Fig.3: Site for retrobulbar block
circulation. It provides a longer duration of Many cases where diplopia developed due to
action and reduces the risk of systemic toxic iatrogenic needle injury to inferior rectus and oblique
effects. It is used in a concentration of muscles by the needle entering at this site have been
1:100,000. reported.8,9 Other complications include retrobulbar
hemorrhage, subarchanoid spread of anesthetic drug,
Types of Regional Blocks oculocardiac reflex, optic nerve compression, globe
Retrobulbar block perforation to name a few.5
This is also known as intraconal block. The injection Peribulbar block
when given in retrobulbar space produces akinesia of This is also known as extraconal block. In this
the extraocular muscles mainly by blocking cranial method the local anaesthetic solution diffuses along
nerves II, III, and VI, leading to globe movement the orbital septum and paralysis of the orbicularis
inhibition.6 It also causes sensory anaesthesia of the muscle along with all the extraocular muscles.10
cornea, uvea, and conjunctiva by blocking of the Technique:

l There are two points of insertion - first at the

43

junction of medial 2/3rd and lateral 1/3rd of akinesia without using a sharp needle. But it cannot be
lower lid adjacent & parallel to orbital floor used in patients of glaucoma surgeries who require
and second is just infero-medial to supra intact conjunctiva for surgery.5
orbital notch or just medial to medial canthus
(Figure 4). Technique
l Take 7-10 ml of anesthetic agent in a syringe l Take a syringe filled with 2 to 3.5 ml of
with 23G needle. anesthetic solution and the put one drop of
l Lower the lower eyelid and expose the lower anesthetic eye drops.
fornix. l One should cauterize the space before
l Insert the needle through the fornix below the incision so as to reduce the risk of
lateral limbus in downwards direction away subconjunctival haemorrhage and preventing
from the globe. Be careful to not pass it for unintended extension of the incision. For this
more than 24 mm. gently apply the bipolar cautery, barely
l The inferotemporal anaesthetic injection (4 to touching but not pressing down on the
5 ml in total) may be divided into three shots: conjunctival surface.
1 ml immediately posterior to the orbicularis l A blunt cannula is inserted after giving
oculi, 1 ml just anterior to the equator, and 2 conjunctival incision is given between
ml after the needle is advanced past the globe. inferior limbus and fornix to open into
l The second injection is given between the posterior sub-tenon's space and the
caruncle and the medial canthus, it is then anesthetic drug is instilled (Figure 5). It leads
passed back and slightly medially for about to blockage of the sensation from the eye due
24 mm, to inject 3 to 4 m of the anesthetic to inhibition of short ciliary nerves as they
solution. pass through the Tenon's capsule in the globe.

Fig.4:Site for peribulbar block Fig.5: Insertion of blunt cannula into space between
tenon's layer and sclera
Peribulbar space communicates freely with the
retrobulbar space. This casuses similar complication Though thought to be safe it has been seen that it may
as seen in retrobulbar blocks. There are high chances cause complications like orbital cellulitis, retrobulbar
of increase in intraocular pressure due to large amount hemorrhage, globe trauma, subconjunctival
of drug injected. This can be prevented by using hemorrhage, and increase in intraocular pressure.
decompression devices and also by giving time for the Failure due to blackflow of the agent has also been
drug to diffuse prior to starting the surgery.5 reported.
Subtenon's block
This is also known as parabulbar or episcleral block. It Pinpoint anaesthesia
is particularly useful for patients who are at high risk It is also known as Fukasaku technique. This
of complications arising from sharp needle blocks technique was developed as a safer alternative to
like patients with high myopia or patients who are on retrobulabar anesthesia. It involves use of a blunt
anticoagulation drugs as it provides anaesthesia and cannula (Figure 6) as compared to a sharp tipped
needle used in retrobulbar block. A small volume of
anesthetic drug is injected in the sub-Tenon's space

44

near the optic nerve at the site of ciliary nerve Fig 7- Facial nerve block sites- 1:van Lint block,
penetration that leads to immediate block of the 2: Atkinson block and 3- O'Brien block
ciliary nerves.11
Technique- A blunt tipped cannula is placed into the In Nadbath-Rehman method, a 25-G needle is used to
subtenon's space and is moved in posterior direction inject local anesthetic directly underneath the mastoid
near the optic nerve. The anesthetic agent is injected at process. The needle is inserted approximately 2 mm
this point. This provides akinesia as well as anterior to the anteriorsuperior border of the mastoid
anesthesia. process, immediately below the external auditory
meatus.12 This leads to blockage of main facial nerve
Fig.6- Fukasaku pinpoint anaesthesia cannula trunk.
Facial nerve blocks
The facial nerve can be blocked at various point in the Fig.8 : Point C shows site of Nadbath-Rehman block
orbit to provide lid akinesia in ocular surgeries. Topical anesthesia
According to injection site, the techniques of the The latest advancement in the anesthetic technique
facial nerve block are usually referred to as: (a) for ocular surgeries is the use of topical medication to
O'Brien block, (b) van Lint block, (c) Atkinson block provide analgesia during surgeries. It is produced by
and (d) Nadbath-Rehman block. These blocks differ instilling local anaesthetic eye drops (0.5%
in injection site and in efficacy of the lid akinesia. proparacaine hydochloride or 2-4% lignocaine)13
In O'Brien block, we palpate the condylar process of which leads to inhibition of corneal and conjunctival
mandible and inject a 25-G needle till it reaches the sensations by blocking of trigeminal nerve. It is useful
bone. 1ml local anesthetic agent is the injected. The in phacoemulsification cataract surgeries, glaucoma
needle is then removed slowly, followed by injections surgery like trabeculectomy14 and also in secondary
first in caudal direction and then in cranial direction intraocular lens implantation. However the usefulness
(around 2-3 ml). also depends upon the surgical skills of the surgeon as
In modified van Lint block, we inject the local well as patient's cooperation is also required.
anesthetic agent at the crossing between a vertical line Preoperative counseling plays role in making the
1 cm lateral of the outer orbital rim and a horizontal patient comfortable for ocular surgery under topical
line 1 cm below the interior orbital rim. Around 2-5 ml anesthesia.
of the anaesthetic solution is injected with a 23-G
needle below the orbicularis oculi muscle along either
line in fan shaped manner.
In Atkinson block, a midpoint of a line between the
lower edge of the zygoma and the jawjoint is marked.
Then 2-5 ml of the anaesthetic solution are injected
with a 23-G needle along this line in both directions.

45

Intracameral anesthesia References
Intracameral anesthesia has emerged as a new 1. Adams A, Jones R. Anaesthesia for eye surgery:
technique for providing ocular anesthesia.15,16
Appropriate patient selection is important when using General considerations. Br J of Anaesthesia.
intracameral anesthesia. Patient cooperation, 1980;52(7):663-669.
anticipated duration of surgery, possibility of 2. Kumar CM, Eke T, Dodds C, et al. Local
complications, axial length, and anticoagulation anaesthesia for ophthalmic surgery--new
status of the patient are some factors to consider when guidelines from the Royal College of
choosing whether or not to use this type of anesthesia. Anaesthetists and the Royal College of
In this technique, 0.2 to 0.5 mL of unpreserved
(methylparaben-free) 1% lidocaine hydrochloride is Ophthalmologists. Eye (Lond). 2012;26(6):897‐898.
injected into the anterior chamber. Intraocular
administration of lidocaine anesthetizes the iris and 3. Kumar, C., & Dowd, T. (2008). Ophthalmic
ciliary body and greatly reduces patient discomfort regional anaesthesia. Current Opinion in
during phacoemulsification and intraocular lens Anaesthesiology. 21(5), 632–637.
insertion. Topical and topical-intracameral anesthesia
techniques have been reportedly associated with 4. Kallio, H., & Rosenberg, P. H. (2005). Advances
lower rates of serious complications such as in ophthalmic regional anaesthesia. Best Practice
retrobulbar hemorrhage, globe perforation, and & Research Clinical Anaesthesiology, 19(2),
traumatic injury to the optic nerve when compared to 215–227.
retrobulbar and peribulbar methods.17
5. Tighe R, Burgess PI, Msukwa G. Teaching
Limbal anesthesia corner: Regional anaesthesia for ophthalmic
Topical anesthesia can lead to corneal toxicity. A surgery. Malawi Med J. 2012;24(4):89-94.
alternative method has been developed to prevent the
corneal toxicity, called limbal anesthesia, in which we 6. Retrobulbar Block: Overview, Periprocedural
apply a cellulose ophthalmic sponge moistened with Care, Technique [Internet]. Emedicine.medscape.com.
preservative-free lidocaine hydrochloride to the 2020.
limbal region for 45 seconds prior to the start of
surgery.18 The main advantage of this technique is the 7. Yanoff M, Duker JS, Augsburger JJ, et al.
lack of epithelial involvement, resulting in a greater ophthalmology. 3rd ed. St. Louis, MO: Mosby;
well-being for the individual and rapid visual 2004. 441-446.
recovery.
8. Gomez-Arnau JI, Yanguela J, Gonzalez A,
Conclusion AndresY, Garcia del Valle S, Gili P. Anaesthesia-
Different techniques are available for providing related diplopia after cataract surgery. Br J
ocular anaesthesia and each has its own advantages Anaesth. 2003;90:189–193.
and disadvantages. No technique is free of
complications. Thus deciding factors for the 9. Taylor G, Devys JM, Heran F, Plaud B. Early
technique depends upon the surgeon's preference, the exploration of diplopia with magnetic resonance
type of surgery, requirement and compliance of the imaging after peribulbar anaesthesia. Br J
patient. An in-depth knowledge of the anatomy of the Anaesth. 2004;92:899–901.
orbit and its spaces and proper training helps in
providing safe and effective orbital regional 10. Jaichandran V. Ophthalmic regional anaesthesia:
anesthesia. A review and update. Ind JAnaesth. 2013;57(1):7-13.

11. Fukasaku H. Sub-tenon's Pinpoint anesthesia .
Ophthalmology Clinics of North America.
1998;11(1):127-129.

12. Nadbath RP, Rehman I. Facial nerve block. Am J
Ophthalmol 1963; 55:143-146.

13. Martini E, Cavallini GM, Campi L, Lugli N, Neri
G, Molinari P. Lidocaine versus ropivacaine for
topical anaesthesia in cataract surgery. J Cataract
Refract Surg. 2002;28:1018–1022.

14. Zabriskie NA, Ahmed II, Crandell AS, Daines B,
Burns TA, Patel BC. A comparison of topical and

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retrobulbar anesthesia for trabeculectomy. J 17. Eke T, Thompson JR. Serious complications of
Glaucoma. 2002;11:306–314. local anaesthesia for cataract surgery: A 1 year
15. Koch PS Anterior chamber irrigation with national survey in the United Kingdom. Br J
unpreserved lidocaine 1% for anesthesia during Ophthalmol. 2007; 91: 470-475.
cataract surgery. J Cataract Refract Surg. 1977;
23: 551- 554. 18. Cagini C, Sbordone GB, Ricci AL, Menduno P.
16. Gills JPCherchio MRainan M Unpreserved Efficacy and safety of limbal anaesthesia for
lidocaine to control discomfort during cataract clear cornea phacoemulsification. Acta
surgery using topical anesthesia. J Cataract ophthalmologica Scandinavica. 2004;82(3 Pt
Refract Surg. 1997;23545- 550. 1):315- 316.

Address for correspondence :

Dr. Sakshi Lochab
Jr. Resident,
RIO, PGIMS, Rohtak.
E-mail : sakshi94lochab@gmail.com
Mobile : 8295444178

47

Anti-VEGFs for Treatment of Retinopathy of Prematurity

Ritesh Verma MS, Satvir Singh MS, Manisha Rathi MS,
Manisha Nada MS, DNB, Sumit Sachdeva MS, Dixit Soni MBBS

Regional Institute of Ophthalmology, PGIMS, Rohtak

Abstract

Anti-VEGF agents in stage 3+ and aggressive posterior ROP have been shown to induce rapid ROP regression.
Significant recurrence rates can require repeat injections and longer term and more frequent follow-ups. Initial
studies reflect conflicting evidence regarding significant systemic side effects of these treatments, and outcomes in
these patients past the first few years of life are yet to be definitively determined. Although anti-VEGF therapies
show promise in the treatment of ROP, frequent recurrences and lack of thorough data about long-term side effects
of pharmacologic intervention necessitate research before anti-VEGF agents become the mainstay of ROP
management.

Keywords: Retinopathy of prematurity, bevacizumab, vascular endothelial growth factor.

Introduction metabolic demands of the developing neural retina
can cause retinal hypoxia, inducing a rapid increase in
Retinopathy of prematurity (ROP) is a VEGF-promoting neovascularization, followed by
vasoproliferative disorder of the retina that is one of the tractional retinal detachment.10 These findings have
major worldwide causes of blindness in children.1-4 important implications for employing anti-VEGF as a
Ablation of the avascular retina by either cryotherapy treatment strategy for ROP during the vasoproliferative
or laser photocoagulation, as shown in the phase. Thus, understanding the VEGF expression in
Cryotherapy for Retinopathy of Prematurity (CRYO- the 2 phases of ROP may help determine the timing of
ROP) study5 and the Early Treatment for Retinopathy ROP management. Intravitreal anti-VEGF injection
of Prematurity (ETROP) study,6 has been regarded as not only acts against the VEGF that has already been
a useful and effective treatment for ROP. Currently, released but also prevents the further release of VEGF
the role of vascular endothelial growth factor (VEGF) if the normal vasculature continues toward the
in the pathogenesis of ROP has been extensively peripheral retina. Accordingly, normal vascular
studied and neovascularisation was found to be development is delayed with VEGF injection, which
primarily driven by VEGF.7,8 The understanding of the is why recurrences after treatment with anti-VEGF
2 discrete phases in the pathogenesis of ROP help can happen very late.
determine the timing of ROP treatment.9
VEGF inhibition
Phase I begins with premature delivery and the
relative retinal hyperoxia of the extra-uterine The vascular endothelial growth factor family has
environment. Supplemental oxygen therapy further many members. Vascular endothelial growth factor
suppresses hypoxia-inducible factor and VEGF, receptor 2 (VEGFR2) is activated in pathologic
which, together with the lack of the non-oxygen angiogenesis, vascular endothelial growth factor
inducible insulin-like growth factor-1 (IGF-1) receptor 1 (VEGFR1) can also be angiogenic, and
formerly secreted by the placenta and required for repeated oxygen fluctuations increased the
VEGF signalling, leads to the cessation of retinal expression of retinal VEGF164. Studies support the
vessel development. In Phase II, further growth of the thinking that VEGF164 and VEGR2 may have roles
neural retina and its high metabolic rate causes in the early and vascular phases of human ROP.11
relative hypoxia, upregulation of VEGF and other Available drugs that inhibit VEGF include pegaptanib
growth factors from the avascular retina, and sodium for partial blockage of VEGF-A, as well as
potential abnormal vessel development. ranibizumab, bevacizumab, and aflibercept for pan-
VEGF-A blockage. Ranibizumab has a shorter serum
Phase II occurs from roughly the PMA of 31 to 44 half-life than bevacizumab, which may theoretically
weeks; it is now understood that this period has a high
risk of ROP development because increasing

48