Page 1 PUBLISHEDBY TOS COPYRIGHT OF TOS, TBM ISSUE 2 - Volume 1: Oct 2023 TOSVISION News letter of the TAMBARAM OPHTHALMIC SOCIETY TAMBARAM OPHTHALMIC SOCIETY 108, Ayyasamy Street, West Tambaram, Chennai-600045 Email: [email protected] _______________________________________________________________________
Page 2 TOS OFFICE BEARERS – (2021–2023) OfficeBearers Names Founder President (2015–2019) Dr. T. Nirmal Fredrick Founder Secretary (2015–2019) Dr. Rachula Daniel Founder Treasurer (2015–2019) Dr. Sheela Ramani Imm Past President (2019–2021) Dr. V. Karunanidhi Imm Past Secretary (2019–2021) Dr. T. Vimala Imm Past Treasurer (2019–2021) Dr. V. S. Vimala President (2021–2023) Dr. Rachula Daniel President Elect Dr. Kavitha Lakshmi K Vice President Dr. Sunitha Nirmal Hony. Secretary Dr. Ramya Chelliah Hony. Treasurer Dr. A. Palaniraj Joint Secretary Dr. Moses Rajamani Joint Treasurer Dr. Uma Devi. J Managing committee member Dr. L. Subha Managing committee member Dr. V. K. Malathi Managing committee member Dr. V. Ganesh Managing committee member Dr. Niranjan Karthick Scientific committee member Dr. T. Vimala Scientific committee member Dr. Anu M Rajadyn Scientific committee member Dr. Soundaram Scientific committee member Dr. Venkatesh Scientific committee member Dr. Chockalingam
Page 3 TABLE OF CONTENTS SL.NO TITLE AUTHOR PAGE NO 1 TNOA PRESIDENT MESSAGE DR.T. NIRMAL FREDRICK 4 2 TOS PRESIDENT MESSAGE DR. RACHULA DANIEL 6 3 TOS SECRETARY REPORT DR. RAMYA CHELLIAH 7 4 CASE SERIES ON OCULAR MANIFESTATION OF SYSTEMIC SARCOIDOSIS Dr. VASMIYA.T, Dr. R. NIRUPAMA 18 5 AN INTRIGUING CASE OF RETINITIS DR. K. SRIKIRUTHIKA, DR. NIRUPAMA RAGOTHAMAN, DR. SHAUN MARIA DACOSTA 25 6 CASE REPORT: SUBCONJUNCTIVAL DIROFILARIA REPENS DR. K. KAVITHA LAKSHMI 31 7 EXERCISE INDUCED NAPHYLAXIS PRESENTING AS BILATERAL PERIORBITAL EDEMA DR. D. GITANJALI FERNANDEZ 35 8 REFRACTIVE SURGERY DR. UMADEVI. J 36 9 DOCTRINE OF RESPONDEAT SUPERIOR Dr. M. CHOCKALINGAM 41
Page 4 TNOA PRESIDENT’S MESSAGE Dear Members of the Tambaram Ophthalmic Society, Greetings to all on the occasion of the 9 th Annual Conference of Tambaram Ophthalmic Society– TOSCON. As the Founder President of the Tambaram Ophthalmic Society and the President of the TamilNadu Ophthalmic Association (TNOA), it is indeed an honor and a privilege to address you all through this newsletter on the occasion of TOSCON – the 9th Annual Conference of the Tambaram Ophthalmic Society, an event that holds a special place in my heart. I am happy and thrilled to witness the remarkable progress that the Tambaram Ophthalmic Society has made since its inception as a small WhatsApp group. From humble beginnings to be coming a vibrant academic and social hub, our journey has been truly inspiring. The dedication and enthusiasm with which the society has grown and taken up the responsibility of organizing conferences as a team are commendable. One of the hallmarks of the Tambaram Ophthalmic Society has been its unity and team work.It's heartening to see how, despite our demanding professional commitments, we come together and work cohesively. The vibrant color coding during every TOSCON and the innovative sessions such as Ignite Talks, orations, awards, and quizzes have added a unique flavor to our conferences, making the meagerly anticipated events. As the President of TNOA, I am delighted to participate in this event and have the privilege of inaugurating the session. It's a testament to our collective efforts and commitment to the field of ophthalmology. I extend my heartfelt thanks to all the past president Dr. V. Karundanidhi, and Dr.Rachula Daniel the current, for their dedicated service and role in building this society.
Page 5 Dr. Rachula, in particular, has played a pivotal role as the Secretary in bringing our grouptogetherandstreamliningthesystemandadministrativeprocesses.CongratulateDr.Ramyachelliah and Dr. Palaniraj for their dynamic tenure, their ability to unite and engage members and hold academic sessions and conferences on a regular basis. Kudos to all the managing committee members and organising team of TOSCON for joining together and keeping theTOS flag high. As we witness the transfer of the leadership to the next team, my best wishes to Dr.Kavitha Lakshmi and the new managing committee. Under the dynamic leadership of Dr.Kavitha, supported by our new Secretary, Dr.Soundaram, and Treasurer, Dr.Niranjan, I am confident that the Tambaram Ophthalmic Society will continue to flourish, attracting new members and fostering allround growth and dynamism. Together, let us aim higher and contribute to the advancement of ophthalmology, stay together to safeguard ourselves from the challenges in the profession, grow to ether and ensuring that quality eye care reaches every corner of our community. I look forward to celebrating our achievements and witnessing the bright future that lies ahead. Thank you for your unwavering support and dedication to our noble profession and Tambaram ophthalmic society. Best wishes for the success of 9th Edition of TOSCON and wishing the new team Godspeed. Warm regards, Prof. Dr.T. Nirmal Fredrick President,TamilNadu Ophthalmic Association
Page 6 TOS PRESIDENT’S MESSAGE GreetingsfromTOSVISION! It is in deed an honour and privilege to present the second issue of TOSVISION: Volume II :Issue 1 [Oct–2023]. I extend my heart felt thanks to our TNOA President and Founder President-TOS, Dr.T. Nirmal Fredrick, who is a pillar of support to TOSVISION and for his inspiring presence at TOSCON 2023 to launch this News letter 2023. We are delighted to see how our Society has grown leaps and bounds from where it started in 2015 and hence it is only appropriate that TOSVISION is being circulated by our Society for the benefit of our members and ophthalmic fraternity. I take this opportunity to congratulate the TOS Life Time Achievement awardee, Dr. Ananda kannan, former Director RIO GOH and Recipient of the 7th Prof V. Velayutham Glaucoma Oration Dr. Krishnadas, for their mentorship and academic excellence. My special thank to our dynamic Secretary-Dr.Ramya Chelliah, Treasurer–Dr.A.Palaniraj, Dr.V.Karunanidhi, and our TOSCON Organizing Committee – Chairperson - Dr. K. Kavithalakshmi , Academic and Organizing team : Dr. Anu M Rajadyn, , Dr. Sunitha Nirmal, Dr. T.Vimala, Dr.J.UmaDevi, Dr.L.Subha, Dr.V.KMalathi, Dr.V.Ganesh, Dr.Niranjan Karthick, Dr.M.Soundaram, Dr.Chockalingam, Dr.N.Anusha, Dr.Nirupama Ragothaman, Dr.K.Rakesh, Dr. Aditya Mahadevan, Dr. C. Venkatesan, Dr. M. Pratheeba, Dr. PremSai for their team work, meticulous planning and organisational excellence. I have no doubt that this conference will be another milestone in the historyof TOS. I thank all the TOS members for their enthusiasm and valuable contributions to the News letter. We look for ward to your continuing support and participation towards our News letter! Happy reading! DR.RACHULADANIEL MD,DO, AFIH PRESIDENT–TOS e-mail :[email protected] Ph: 9962421779
Page 7 TOS SECRETARY’S REPORT 2022 - 23 Tambaram Ophthalmic Society enters the ninth year in 2023, of continuous academic and professional growth under the guidance of the founder president Dr.T. Nirmal Fredrick, founder secretary Dr.Rachula Daniel and founder treasurer Dr.Sheela Ramani. TOS was formally inaugurated on 23.08.2015 by the then TNOA president Dr. K.Premraj and registered under the Tamilnadu societies registration act, 1975 on 21.07.2016,sl.no:339/2016.TOSwas affiliated to TNOA in Aug 2018. TOS has so far successfully conducted 25 Continuing Professional Development programs and eight Annual Conferences–TOSCON s with the support of a strong team base. The new Office bearers, President Dr. Rachula Daniel, Secretary Dr.Ramya Chelliah and the Treasurer Dr.A. PalaniRaj, took over their tenureship from2022. As part of the community reach program, The Tambaram Ophthalmic Society ( TOS) conducted the World Glaucoma Week observance, in association with WGA, GSI, TNOA,MCOA, Bharath Medical College and FORWA (Federation of residents welfare association) from 6-12 March 2022. Theme: The World is bright, save your sight !
Page 8 Glaucoma awareness walkathon was held on 13.03.2022 in Agaramthen Road. There were more than 300 participants from diverse age groups, including five year old kids and people from all walks of life, participating very enthusiastically. The program was presided by the chief guest Dr.M.Elangovan, commissioner Tamabaram corporation, guests of honour, Dr.MohanRajan president, TNOA and Lion.R.Govindarajan, president FORWA.
Page 9 The athletic challenge 10 km run/ walk was flagged of at 5.30 am from Agaramthen Road, by Chief guest Dr.M. Elangovan, Commissioner Tambaram Corporation , Dr. Mohan Rajan – President - Tamilnadu Ophthalmic Association (TNOA), Dr.Nirmal Fredrick, Vice President - TNOA & Founder President -TOS,Dr.Elumalai – Dean, Bharath Medical College. The Tambaram Fit and Spin Doctors’s challenge grand finale was also successfully completed.
Page 10 23rd TOS CPD PROGRAM – 17th July 2022 The 23rd CPD was on FOCUS ON PEDIATRIC EYE CARE and the practice management session comprised of a panel discussion on CHALLENGES AND OPPORTUNITIES IN OPHTHALMIC PRACTICE. Dr. Manjula Jeyakumar spoke on “Strabismus that a general ophthalmologist can tackle”Dr.AnkitaBisani spoke on“Myopia– update in management” Ms.BenitaSharon spoke on“Spectacle dispensing in pediatric patients. TOSCON2022 The 8th Annual Conference of the Tambaram Ophthalmic society was held at Hotel Hablis on 2/10/2022.TheChiefguestwas Dr R.Ramakrishnan-President TNOA and the Guest of honour was Dr Senthamil Pari , President elect IMA TAMIL NADU. The 4 th Lifetime Achievement Award was given to Capt Prof Dr V M Loganathan. The 6 th Prof Dr V. Velayutham Glaucoma Oration was delivered by Dr. Ronnie Jacob George.
Page 11 We had lively and informative scientific sessions: 1. Cornea and dry eye session,VASTsessiononCataractsurgeryand Glaucoma session 2. Practice management session:keynoteaddress–challenges related to insurance billing: Dr HarikrishnaVannadil 3. Panel discussion on insurance issues in ophthalmology 4. Ignite session: 9 participants 5. Quiz programme on Ocular Fundusphotographs Yet another interesting event was the launching ofour first newsletter – TOSVISION and it was released by Dr R Ramakrishnan president of TNOA and first copy was received by Dr Senthamil Pari- President elect-IMA TamilNadu. 24th TOS CPD-4 DEC2022 The 24th CPD program was on “Do away with the Ophthalnightmare–Endophthalmitis” 1. Plan and principles of infection contro lby Dr.NirmalFredrick.T 2. Performing sterilization by Dr.KumaranM 3. Preventing infection by Dr.SrinivasKRao 4. Predict and treat endophthalmitis by Dr.Brahadeesh S 5. Practice management session included a panel discussion on, Principles and Protocols for Infection Control in Ophthalmology
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Page 15 25 TOS CPD –26 March 2023 The 25th CPD was on Glaucoma- the silent thief of sight 1. Managing coexisting glaucoma and cataract by Dr Nirmal Fredrick 2. Common diagnostic errors in glaucoma by Dr Rathini David Practice management session included a panel discussion on Diagnostic dilemmas and treatment solutions for glaucoma.
Page 16 Community out reach program – Glaucoma walkath on-7 thApr 2023 The Tambaram Ophthalmic Society strongly believes in health and fitness of its members. Celebrate the world health day, we teamed up with Tambaram IMA spin and fit doctors group and concluded the World Glaucoma Week fitness challenge on 7th Apr 2023. The 10km and 5km was flagged off by the IMA TBM and TOS leaders. The event concluded with distribution of prizes and medals which were given away by our special guests, Mr.Ashwin kumar R, lawyer turned social worker, president of the NGO and Dr. Arunkumar Selvaganapathy, laparoscopic surgeon and anultramarath on runner.
Page 17 26thTOSCPD -18thJune2023 26th CPD on Aesthetics in ophthalmology 1. Aesthetic approach around the eye by dermatologist, Dr. Aarthi L 2. Periocular surgical rejuvenation of the aging face by Dr. Senthilnathan. C 3. The what and how of Perior bital rejuvenation by plastic surgeon Dr.Rajendran. P 4. Practice management session included a panel discussion on Promote, prepare and practice aesthetics. MC MEETING AT NIRMALS’ EYE HOSPITAL – AGENDA TOSCON 2023 Dr.Ramya Chelliah Secretary – TOS
Page 18 CASE SERIES ON OCULAR MANIFESTATION OF SYSTEMIC SARCOIDOSIS VasmiyaT (Resident, DNB ophthalmology) R Nirupama (Consultant, cataract and uvea, Sankara Eye Hospital, Pammal Introduction Sarcoidosis is a multi system granulomatous disease which can manifest with ocular involvement in a significant number of cases. This case series highlights the bilateral and bimodal presentation of ocular sarcoidosis while underscoring the importance of investigations, particularly highresolution computed tomography (HRCT) and biopsy, in confirming the diagnosis. Additionally, the bimodal age distribution emphasizes the significance of age-related risk assessment for timely diagnosis. HRCT chest imaging plays a crucial role in identifying pulmonary parenchymal changes, such asbilateral hilar lymphadenopathy and fissural nodules, supporting the diagnosis of systemic sarcoidosis1 . Biopsies of affected tissues provide invaluable insights into the characteristic non-caseating granulomas, confirming ocular sarcoidosis and ruling out other granulomatous diseases. Case1 A 40-year-old female presented with redness, photophobia, and pain in both eyes. Her visual acuity was 6/12 in the right eye and 6/24 in the left
Page 19 eye. Ophthalmic examination revealed bilateral granulomatous intermediate uveitis with Berlin Nodule, and fundus findings showed snowball opacities in the inferior quadrant. Initial lab work up indicated an elevated serum angiotensin-converting enzyme(ACE) level (134.8 U/L) and negative Mantoux and HLA-B27tests. Quantifer on TB gold test was also negative. The patient received oral steroids, azathioprine, topical steroids, and cycloplegicsas treatment. However, she was unfortunately lost to follow-up until February 2023, when she returned with recurrent uveitis and eyelid granulomas. HRCT chest scan revealed multiple perilymphatic and perifissural nodules with bulkylymphadenopathy involving the paratracheal, perivascular, bilateral hilar, and subcarinal regions. Video Bronchoscopy showed granulomatous lung disease. BAL cytology was negative for acid-fast bacilli, and the transbronchial lungbiopsy confirmed non-caseating granulomas. In response, treatment with deflazacort was initiated, leading to an improvement in ocular findings during follow-up. Eyelid granuloma Both eyesseclusiopupillae with Berlinnodule
Page 20 CASE2 In November 2021, a 32-year-old female presented with recurring redness in both eyes, persisting for two years. Her right eye had an uncorrected visual acuity (UCVA) of 6/6, while the left eye had a reduced UCVA of 5/60. Bilateral granulomatous inter mediate uveitis with Busacca nodules was observed during examination, along with snowball exudates and choroidalnodules in both fundi. Further investigations, including HRCT chest, revealed prominentmediastinal lymph nodes. Her serum ACE level was 44.7U/L (with in the range of 8-52U/L), and the Quantifer on TB test results were negative. Treatment was initiated with topical steroids, cycloplegics, methotrexate (IMT), and oral steroids. Figu
Page 21 The patient was lost to follow-up until August 2022, resulting in disease recurrence. Upon reinitiating the treatment, right eye discedema and left eye optic disc granuloma, along with multiple choroidal granulomas in the midperiphery and inferior quadrant, were found during the fundus examination. However, her visualacuity improved to 6/6 in both eyes by January 2023, and her symptoms resolved. A-Busaccanodules. B-Discedema right eye. C-Inferiorquadrant-Snowball exudateandchoroidalnodule. D-Discgranuloma left eye Case 3 In February 2023, a 50-year-old female presented with a one-day history of redness, pain, and photophobia in both eyes. She also reported a three-month history of fever and consulted a physician. Initial investigations for PUO were performed but showed negative results. The patient also had persistent axillarylymphadenopathy, leading to further investigations, including aPET- CT. During ophthalmic examination, fine keratic precipitates, endothelial dusting, and Koeppe's nodules were observed, and adiagnosisofbilateralnon-granulomatous anterior uveitis (BE) was made. Fund us examination was normal. Given the concern for the possibility of malignancy, sarcoidosis,TB, an extensive evaluation was carried out, involving HRCT chest, serum ACE, Quantifer on TB test, and
Page 22 PET-CT. CBC, ACE (40 U/L)and peripheral smear results were normal, but elevated ESR and CRP levels were observed. Quantifer on TB was negative. Cardiac evaluation showed no abnormalities. The PET-CT scan revealed bilateral axillary, brachial, hilar, mediastinal, and cervical lymphnode involvement, along with enlarged mesenteric, portocaval, periportal, retroperitoneal, iliac, inguinal, pop liteal nodes, and splenic involvement, which raised the suspicion of a stage 3lymphoproliferativedisorder. A-Koeppe' snodules. B-Anterior chamber cells and flare To confirm the diagnosis, an axillary lymph node biopsy was performed, revealing non- caseating granulomas, confirming systemic sarcoidosis and ruling out malignancy. Treatment with methotrexate and oral steroids was initiated, leading to improvement during follow-up.
Page 23 Discussion This case series highlights the significance of ocular involvement in sarcoidosis, which presents in approximately 30-50% of cases2,3,5.Uveitis is the most common ocular manifestation, affecting 30-70% of sarcoidosis-related eye conditions. The ocular manifestations of sarcoidosis include mutton fat keraticprecipitates, Koeppe's nodules, and Busacca nodules, with 50% of patients exhibiting these features in sarcoid associated anterioruveitis2,3,5. Additional findings include Berlin's nodules, tent-shaped peripheral anterior synechia, eyelid granulomas, and conjunctival granulomas2 . Posterior segment involvement is seenin 14- 43% of sarcoidosis cases and is characterized by snowballs or strings of pearls in the vitreous, multiple chorioretinal peripherallesions, candle wax drippings, optic disc granuloma, or solitarychoroidal granuloma2 . Bilaterality is common, noted in 86% ofcases4 . The clinical presentation varied across the presented cases, ranging from Koeppe's nodules, Busacca nodules, and Berlinnodules in the anterior segment to snowballs in the vitreous, optic disc edema, optic disc granuloma, and choroidalgranulomain the fundus. This case series also emphasizes the importance of timely and comprehensive investigations, such as HRCT, bronchoscopy,andPETCT,whichplayacrucialroleinconfirmingthediagnosis and guiding appropriate treatment. Other investigations that can aid in diagnosis, such asserumlysozyme,
Page 24 gallium67scintigraphy,or18F-FDGPETimaging, and CD4/CD8 ratio in bronchoalveolar lavage5 , were not performed in some patients due to financial constraints. This case series further underlines the significance of patient education and counseling, stressing the importance of regular monitoring to enhance compliance and significantly reduce theriskofrecurrence.Collaborativecareinvolvingophthalm ologists,pulmonologists, and specialists in internal medicine ensuresoptimal outcomes in managing ocular sarcoidosis. Hence it is vital to raise awareness among the medical community and encourage interdisciplinary approaches for the best possible patient care. References: 1. High Resolution Chest Computerized Tomography in the Diagnosis of Ocular Sarcoidosis in a High TBEndemic Population KalpanaBabu1,Sai Bhakti Shukla 1,Mariamma Philips . 2. Baughman RP, et al. Statement on sarcoidosis. Am J Respir Crit Care Med.2020;201(3):e26-e45. 3. Ocular manifestations of sarcoidosis TS Nowinski 1. 4. Distinguishing Features of Ocular Sarcoidosis in an International Cohort of Uveitis Patients Nisha R Acharya 1, Erica N Browne 2, Narsing Rao 3, Manabu Mochizuki 4;International Ocular Sarcoidosis Working Group. 5. Revised criteria of International Workshop on Ocular Sarcoidosis (IWOS) for the diagnosis of ocular sarcoidosis Manabu Mochizuki 1 2, Justine R Smith 3, Hiroshi Takase 4, Toshikatsu Kaburaki 5,Nisha R Acharya 6, Narsing A Rao 7; International Workshop on Ocular Sarcoidosis Study Group. 6. Dr.KalpanaBabu, Ocular Sarcoidosis Treatment Guidelines.
Page 25 AN INTRIGUING CASE OF RETINITIS Dr K SriKiruthika, Dr Nirupama Ragothaman, Dr Shaun Maria Dacosta Sankara Eye Hospital, Pammal Introduction: The term "post-fever retinitis" (PFR) refers to different retinal manifestations that occur after a systemic febrile illness, which can be caused by bacteria, viruses, or protozoa. Typically, these manifestations appear with in two to four weeks after the fever in immune competent patients, regardless of the specific cause of the febrile illness. Post-fever retinitis can occur through two main mechanisms. Firstly, it can result from a direct invasion of the retina by apathogen during the febrile illness. Alternatively, it may be mediated indirectly through animmune response triggered by the preceding fever. Regardless of the specific mechanism, the common presentation of post-fever retinitis involves a sudden and significant reduction in vision. In this case report, we detail the clinical characteristics and treatment outcome of a case of post fever retinitis in a 26year old male patient.
Page 26 Case discussion: A 26 year -old male presented with a gradual painless decrease in distant vision in the right eye for 2weeks. He gave a history of travel to Goa 20 days back and developed high grade intermittent fever with chills and rigor after return from Goa and had been treated with oral antibiotics and antipyretics. Patient also developed vesicles on both forearm and knees leaving behind pigmented scars. He also had history of fleeting joint pain. On ocular examination, his best-corrected visual acuity (BCVA) was 6/12 in the right eye and 6/6 in the left eye. Anterior segment examination showed anterior chambercells 2+ and flare with a clear lens and vitreous cells in the right eye. Anterior and posterior segment examination was unremarkable in left eye. Fundus examination of the right eye revealed disc edema with blurring of disc margin. Multiple discrete bright yellow foci of Retinitis with overlying superficial hemorrhage were found in the inferior margin of the disc and with in the super otemporal arcade above the macula. Hardexudates were arranged in the form of macular star with serousretinal detachment at the macula.
Page 27 The optical coherence tomography (OCT) through the macula with fovea at centre showed inner retina thickening with hyper reflective dots suggestive of hard exudates and serous retinal detachment at fovea
Page 28 with cystic spaces. OCT through the retinitis patch showed increased hyper reflectivity with thickening of the inner retinal layer sand shadowing of the outer layers. Subsequently, aseries of investigations were conducted, including complete blood count, peripheral smear, erythrocyte sedimentation rate, C-reactive protein, Mantoux test, serology test for HIV, IgM and IgG for salmonella, leptospira, dengu and TORCH panel allof which showed results within normal ranges except elevated CRP and ESR. AC Tap-RTPCR for chikungunya virus done and it was negative
Page 29 A diagnosis of Immune-mediated post fever retinitis was made, considering a latent period of two weeks between the fever and visual symptoms, and the laboratory tests showing negative results for pertinent causes of infectious retinitis. The patient was treated with oral steroids at adosageof1mg/kg bodyweight and oral doxycycline 100mg BD for 2 weeks. During subsequent follow-ups, the steroids were gradually tapered on weekly basis over a period of 6 weeks as the retinitis lesion showed regression. After 4 weeks of treatment his vision improved to 6/6 parts with resolution of serous retinal detachment at fovea. Conclusion: Standardized treatment protocol for post-fever retinitis (PFR) is not established. Due to the diverse possible causative organisms and the involvement of inflammation in the condition, the treatment approach remain sempirical and individualized.
Page 30 In cases of PFR, where the causative organism is suspected, empirical treatment typically involves a combination of antibiotics with extended spectrum to cover various gram positive, gram negative and atypical organisms along with steroids to address the inflammatory process and reduce inflammation in the affected retinal tissues is advised. The use of steroid helps in managing the symptoms and alleviates the immune-mediated response that often occursin PFR. After a careful analysis of the presenting signs and symptoms of the febrile illness, an aqueous tap – PCR analysis may be performed. Positive response to steroids, regardless of the specific infectious agent involved, suggests a possible immunological component in the development of post-fever retinitis. It is essential to emphasize that treatment decisions should be made by healthcare professionals based on the patient's specific clinical presentation, medical history, and laboratory results. Individualized care is crucial to achieve the best possible outcomes in managing post-fever retinitis.
Page 31 CASE REPORT: SUBCONJUNCTIVAL DIROFILARIA REPENS Dr K Kavitha Lakshmi, M.S( Ophthal) FMRF(Phaco) Director & Chief Ophthalmic Surgeon, Dr K K Surgical & Paediatric Centre,EastTambaram,Selaiyur,Chennai600073. Casereport A 74-year-old woman presented to our Centre with complaints of redness, irritation and watering in her right eye since 2 days. She gave no history of any nodules or rashes on her skin. She had no history of recent travel. She gave a history of feeding street dogs. On preliminary examination, the right eye had mild conjunctival congestion. Her vision was 6/6 in both eyes without glasses. She had been operated for cataract with IOL implantation 15 years ago. She is a known Diabetic and hypertensive and is under good control with medications. Slit lamp examination revealed a live motile worm in the temporal part of the subconjunctival space of her right eye. The overlying conjunctiva was injected. There was no inflammatory reaction in the anterior chamber. Dilated fundus examination of the eye was normal. Computed tomography of brain and orbits revealed no abnormality. Stool examination was normal. There was no hepatomegaly or splenomegaly. Her hemogram, including eosinophil counts was normal. She consented to have the worm remove din the operation theatre. Under topical anesthesia, the conjunctiva was incised and the worm was easily removed in its entirety with forceps. Gatifloxacin eye ointment was applied 3 times a day for one week along with Prednisolone eye drops in tapering doses.
Page 32 Systemic de worming with Ivermectin and a course of Hetrazan was also given. Patient was followed up for three weeks. Congestion in the eye settled down on topical treatment with steroids and antibiotics. The worm, measuring around 7.5 cm in length was placed in a vial containing 70 %ethanol and sent for analysis including PCR. The microscopic appearance and PCR analysis confirmed it to be an adult (Sub adult) Dirofilaria repentis nematode. Herperipheral smear for microfilaria was normal. Her eosinophil count was also normal. One week later, the conjunctiva had healed well and the rest of the eye was unremarkable. Our patient remains completely well. Discussion The genus Dirofilaria belongs to the family On chocercidae of the order Spirurida and phylum Nematoda. This parasite is found in dog, cat, raccoons, bear and other wild animals. It replicates in the animal’s body and enters circulation in the form of microfilariae, which are transmitted to other animals or humans by mosquito (Culex,Aedes,orAnopheles) bites, which a real so intermediate hosts. Third-stage larvae are introduced onto the skin during a blood meal from an infected mosquito, where they penetrate the wound to reach the sub cutaneous tissue. It was not possible to ascertain the precise pathway from inoculation to adulthood in this case, but we speculate that amosquito bite close to the site was responsible. Humans are aberrant hosts in which D. repens larvae can sometimes reach the adult stage. Although they are not thought to reach sexual maturity in the majority of cases, there are sporadic reports of micro filariae found in the peripheral blood. The most common Dirofilariaspp. causing infection sin humans are D. repens and D. immitis. This nematode parasite caus e pulmonary, ocular or subcutaneous lesions in humans who are dead end host. The worm is usually localised and confined to the subcutaneoust issues of eyelids, fingers, cheeks and breasts.
Page 33 Ophthalmic involvement is usually periorbital, intraocular or in the eyelids. Sub conjunctival localization is also reported. D. repens has been more commonly associated with dirofilariasisin India, irrespective of anatomical sites involved. Redness, swelling, increased lacrimation with foreign body sensation are the presenting features. Conclusion This rare case highlights the possibly increasing incidence of human dirofilariasis. Human infections caused by Dirofilaria spp. are usually undiagnosed and are mostly under reported due to lack of awareness and constraints in diagnostic modalities. Awareness, high index of suspicion with morphological identification of the parasite are the keys to diagnose human dirofilariasis removed under topical anaesthesia. Dirofilariarepens Subconjunctivalliveworm Measures 7.5 cm
Page 34 microscopicexamination PCRAnalysis Wormin70 %Ethanol
Page 35 EXERCISE INDUCED ANAPHYLAXIS PRESENTING AS BILATERAL PERIORBITALEDEMA Dr D Gitanjali Fernandez Senior Consultant - Medical Retina and Neurophthalmology Centre for vision eye hospital Sholinganallur A 12 year old, was brought by his mother with complaints of bilateral lid swelling for2 days. There was no significant systemic history. The child has been an avid sportsperson from the age of 7 to 8 years. He was into football and cricket. There was no family history of systemic illness. There was no history of any medication. On slit lamp examination, there was boggy periorbital edema, cojunctiva, cornea , pupils and lens appeared normal. There was no itching. There was no history of systemic allergy. The mother gave history of 10 episodes in last 5 months. Each of the episodes resolved spontaneously either on few hours or few days without any topical medication. The child continued his running even though he developed episodes of lidedema in between. There were no visual complaint. Topical steroid and antibiotic combination eye drops was prescribed for this episode. Literature search about exercise induced anaphylaxis, defined it as occurrence of anaphylactic symptoms (skin, Respiratory, cardiovascular, gastrointestinal) after physical activity. In a third of cases, associated factors were food intake, NSAIDS, and warm or cold climate. Treatment of acute EIA, was injection epinephrine, intramuscular, (1:1000), 1 mg/ml, at a dose of 0.2 to 0.5 mg/ml in adult sand 0.01mg/ml in children. However in this child, except for the periorbitaledema, there was no systemic involvement. Avoidance of trigger remains the main Treatment. Diagnosis of EIA, requires careful diagnosis because of the risk of life threatening reactions.
Page 36 REFRACTIVE SURGERY Dr. J. Umadevi, MBBS., DO.,FAICO., Senior Consultant Refractive Surgery and Medical Retina Services, Dr.Agarwal's Eye Hospital, Tambaram, Chennai Refractive surgery refers to surgical alteration of the eye to correct refractive errors. The first well developed refractive surgery called Keratomileusis was (carving the cornea) developed by Jose Ignacio Barraquer (Colombia)in 1949.Heis the Father of modern Refractive surgery. THEGOALOFREFRACTIVESURGERY: To reduce the dependency of an individual on spectacles or contact lenses for their daily routine activities. REFRACTIVESURGERYCLASSIFIEDAS, REFRACTIVESURGERIES CORNEALPROCEDURE LENS BASED PROCEDURESLASERVISIONCORRECTION ICL RLE (Intra cameral lens Implantation / (Refractive lens exchange/ Phakic IOL implantation) Clear lens extraction
Page 37 Flap procedures Flapless procedures 1. FLEx 1.ReLExSMILE 2. Femto LASIK 2.StreamlightPRK/ Trans PRK 3. LASIK– Blade 3.PRK(Photo refractive keratectomy) BIOPTICS&TRIOPTICS: Corneal and Intra ocular procedures can be combined to deal with high refractive errors. This is called Biopticsif two procedure are combined and Triopticsif three procedure are combined. PREOPERATIVEEVALUATIONANDINVESTIGATIONS: In Refractive surgery services choosing the right procedure to the right patient is far most important by assessing the patient thoroughly with history taking, clinical evaluation and investigations. Spending sufficient pre operative chair time with patient helps to avoid post operatively unsatisfied patient. Contact lenses must be removed prior to preoperative evaluation and surgery for 7-14 days period for Soft Contact lenses and 3 weeks for RGP lenses (Corneal Wa rpage- Contact lens Use). ELIGIBILITYCRITERIA: Stablerefractionfor1year. 1. CORNEALPROCEDURES:-1 DSto– 10.00DS,Cylindricalpower upto4D 2. ICL: Unfitto laser visioncorrection(Upto-18.00 (ACD>2.8mm)) 3. REFRACTIVE LENS EXCHANGE: HighMyopia a. Unfit for LVCand ICL b. Around40yearsor>40 years Age–Above18yearsto45years 35yearsto45years age group only to HIGHMYOPES (Pre and pres by opiaage group to be explained clearly about need for near vision glasses post-surgery.)
Page 38 CONTRA INDICATIONS: Unstable refractive error. • Diseases to the eyes affecting visual axis- Corneal Ectasias, Opacities, cataract, retinal pathology Un control ledglaucoma. Un controlled dry eye diseases Autoimmune diseases Insufficient reside corneal thickness Unrealistic patient expectation. Pregnancy & lactation PREOPEEVALUATION: Refraction- with Cycloplegicdrops Schirmers IOP documentation with AT Through anterior and Posterior segment evaluation Corneal Topography and Tomography Fundus photo Imaging for future reference Specular Microscopy for Thick corneas-CCT >580 um Lab investigations-RBS, Hb %&Serology Duct Syringing PREOPEMEDICATIONS: Anti biotic drops 1 hourlyfrom1 day before surgery till the time of surgery. Lubricant drops according to Schirmers Value. Tab.Anxit0.25mg1 day before surgery at night and on the day of surgery. SURGICALPROCEDURE: Flap procedures Flapless procedures 1. FLEx 1.ReLExSMILE 2. Femto LASIK 2.StreamlightPRK/Trans PRK 3. LASIK– Blade 3.PRK(Photo refractive keratectomy) EXCIMER LASER-PHOTOABLATION FEMTOSECOND LASER-PHOTODISRUPTION
Page 39 POSTOPERATIVECARE: 1. Restvariesfrom3days(SMILE)to1 week period (others) 2. Head bath and face wash to be avoided for 7days post-surgery. 3. Eye makeup should be avoided for 1 month post surgery 4. avoid ball games / heavy gym activities for 1month post surgery ReLEx SMILE ReLExSMILE(RefractiveLenticuleExtractionSmallIncisionLenticuleExtraction),isaadvancedflaplesscornealrefractivesurgicalprocedure usedtocorrecttheMyopiaandCompoundMyopicAstigmatism. It is aminimally invasive keyhole LASER vision correction procedure(LVC). ReLex SMILE is the most preferred LVC procedure considering its safety, comfort and speedy recovery. FEMTO second LASER isused to create the lenticule. SURGICALPROCEDURE -2STEPS: Step1-LASERapplication(30sec-FEMTOlASER) Step2- Dissection and removal of The Lenticule EXCLUSIONCRITERIA: Myopia>-10.00D Astigmatism>3D Pachy<480µ Residual BedThickness<250µ Abnormal posteriorelevation(BAD) Corneal opacity ADVANTAGES: SMILE-Flaplessprocedure–Therefore: No flap related complications. Corneal nerve innervations less disrupted in SMILE procedure, therefore faster recovery of Corneal Sensation and Dry Eye. Due to relatively intact anterior stronger layers of Corneain SMILE procedure helps in better maintenance of Corneal Bio mechanical strength. Entire surgical procedure is done in single surgical suite with Femto Second LASER and it helps to reduce the surgical procedure time.
Page 40 DISADVANTAGES: Inability to treat Hyperopia Absence of Cyclotorsion Correction COMPLICATIONS: INTRAOPERATIVE COMPLICATIONS: Suction loss OBL Black spot Difficult disection Retained Lenticule/ Fragments Captear / Incisionaltear Sub Conjunctival hemorrhage Decenteredablation POSTOPERATIVECOMPLICATIONS: Inter faceHaze Interface Debris Interface opacities Under correction Overcorrection Epithelial In growth SMILEPRO SMILE PRO (Small Incision Lenticule Extraction) is the latest version of the SMILE technique in laser eye surgery. Known as 'keyhole' laser eye surgery, it is minimally invasive LASER vision correction procedure, faster than SMILE procedure and reduces the risk of Suction loss during the surgery. The recovery time is also quicker and there is less chance of infection and dry- eye associated with other procedures. ADVANTAGESOFSMILEPRO: Faster than SMILE surgery Cyclotorsion- can be corrected Hyperopia correction included in the machine (Future)
Page 41 DOCTRINE OFRESPONDEATSUPERIOR Dr. M. Chockalingam DO DNB FRCS (Glasgow) PGDHHM Medical Director, Vignesh Meenu EyeClinic 4/5,Pillayar Kovil Street Devi Nagar, Porur, Chennai - 600 116 www.vigneshmeenueyeclinic.co.in Respondeant superior (Latin: "let the master answer"; plural: respondeant superiores) is a legal doctrine holding a party (employer) liable for the wrongful acts of agents (employees). This rule is also called the master –servant rule. According to this doctrine, a health care organization is liable for the negligent acts of its employees even though there has been no wrongful conduct on the part of the organization. LIABILITY BASED ON RESPONDEAT SUPERIOR The duty of the health care service provider is to possess and exercise, through its employees, reasonable care practiced by similar institutions. When liability is asserted on the basis of respondent superior, three questions should be answered, namely 1. Was atort*committed? Was the person who committed the tort an agent oran employee of the defendant? 2. Was the tort committed with in the scope of the agent’s or employee’s duties? In short, the doctrine of respondeat superior simply states that an employer is liable to a third party for the tort that an employee has committed within the scope of employment. The alleged tort in a respondeat superior may be a tort of negligence or an intentional tort. Intentional tort results when a person intends to do the wrongful act (examples include defamation, invasion of privacy, wrongful disclosure of confidential information etc.) The employer is answerable for the employee’s negligence even though is not directly at fault. Hence this doctrine is also referred to as vicarious
Page 42 liability. Some examples of respondeant superior for which both the employer and employee are liable for their acts are 1. Amedicalassistant(forexample,aphysicianassistant,nurse,intern,resident)givest hewrongmedicationtoapatient.Asaresult,thepatientbecomessickandrequireshospitalizatio n.Thedoctorwillbeheldliablefortheactions of the medical assistant. 2. A resident giving local anaesthesia to the wrong eye other than the one scheduled to be operated by the consultant. JUSTIFCATION FOR THE LIABILITY BASED ON RESPONDEAT SUPERIOR The reasons for fixing the liability on the employer for the negligent act of the employees is due to the following reasons:- 1. An organization can act only through employees; to hold the organization not liable for the individuals’ actions would mean that the organization could never be held responsible for decisions taken and acts committed in further anceofitsaims. 2. The employer exercises the right to control the means and methods of the employee’s work and therefore is responsible for the employee’s acts during the course of his/her employment. 3. When there is negligence on the part of the employee during the course of his employment, both the employer and employee are joint defendants although the employer is the primary target for recovery of damages because of its “deep pockets.” In other words, the basis for holding the employer vicariously liable is because it is the organization which has superior financial means of compensating for the damages caused by the employee. 4. The imposition of the liability will encourage the employer to Develop and implement sound procedures and clinical guidelines based on evidencebased practice for controlling employees’ performance in his job. Get accreditation of the organization and this will improve operational efficiency and reduced liability cases.The Accreditation of hospitals compels them to adhere to guidelines and regulations and therefore stay clear of legal mishaps in the care of patients. Accreditation tells insurers and the public that you value safety, that you’ve made acommitment to best practices and regulatory requirements. Because the basis of respondeat superior is the employer’s right to control the means and methods of the employee’s work, it logically follows that the employer is not liable vicariously for the tort or negligence of an independent contractor. In the field of h ealthcare organization, a physician in private practise who is also a member of medical staff of an organization with certain delineated privileges has been considered as an
Page 43 independent contractor. For example, a consultant working on a fee for service basis (either part time or full time) in a health care organization (corporate healthcare organization) is considered as an independent contractor. The applicability of the doctrine of respondeat superior to an independent contractor and it’s evolution over time will be covered in the next part of this series. *Tortisacivil wrong or wrongful act, whether intentional or accidental, from which injury occurs to another. Torts include all negligence cases as well as intentional wrongs which result in harm.
Page 44 "One flower is beautiful, but a field of them growing together is breathtaking"