DJO Vol. 32, No. 3, January-March 2022
E-ISSN: 2454-2784 P-ISSN: 0972-0200 2 www.djo.org.in
DJO Vol. 32, No. 3, January-March 2022
Delhi Journal of Ophthalmology DJO
Official Journal of Delhi Ophthalmological Society Editorial Board Volume 32 Number 3 January-March, 2022
Editor-in-Chief
Kirti Singh
Associate Editors
Annu Joon Devesh Kumawat Divya Jain Mainak Bhattacharyya
Arshi Singh Assistant Editors Priya Saraf
Khushboo Chawla
Akanksha Ankita Bhardwaj Section Editors Bhumika Sharma Charu Khurana
Deepanjali Arya Gunjan Budhiraja Jatinder Bali Jatinder Bhalla
Jigyasa Sahu Manisha Agarwal Anjali Mehta Neha Rathie Nisha Chaudhary
Palak Gupta Pooja Bansal Himshika Aggarwal Priyadarshi Gupta Priyanka Golhait
Prachi Dave Rahul Mayor Neha Chawla Ritu Aurora Shipra Sharda
Shweta Vishwanath Siddharth Baindur Prateek Kumar Sumit Grover Siddharth Madan
Tanvi Gaonkar V.Krishna Rajat Jain Vaibhav Nagpal Vineet Sehgal
Suma Ganesh
Vaibhav Khanna
International & Emeritus Editor
Arun Naryanswami Bhavna Chawla George L. Spaeth Milind Pande M. Vanathi
Rajesh Sinha Samira Khan
Vinod Kumar Ruchi Goel Sonal Dangda Satish Kotta
A. K. Grover Atul Kumar Advisory Board Deepak Verma Jolly Rohtagi
J.S.Titiyal Mahipal S. Sachdev N.P. Singh Namrata Sharma
Pawan Goyal Pradeep Sharma Bithi Chowdhary Rakesh Bhardwaj Ramanjeet Sihota
Ritu Arora Rajender Khanna M.D. Singh Suneeta Dubey S.C. Dadeya
Praveen Vashisht
Sarita Beri
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DJO Vol. 32, No. 3, January-March 2022
Contents
Editorial
Empathy and Human Connect: Winning Combination for i- Drugs Adherence ..................................6
Kirti Singh
Guest Editorial
Detrimental Effects of IrrationalDrugTherapyonThe OcularSurface.............................................................7
Abha Gour, Virender S Sangwan
Review Article
Paucity and Dearth of Eye Health Education Material (EHEM) In Hindi Language on Internet....................11
Abha Shukla, Divya Rana, Kirti Chhabra, Rashmi Kujur
Steroid Induced Glaucoma: Dilemma Decoded.............................................................................................15
Shalini Mohan, Shweta Tripathi, J S Bhalla, Kanika Jain, Ashwini Kulkarni
Multimodality Imaging in Mechanical Orbital Trauma..................................................................................20
Ebinesh A, Alpana Manchanda, Radhika Batra, Apoorva Sehgal
Original Article
High Diagnostic And Therapeutic Value of Digital Subtraction Angiography in Direct Carotid-Cavernous
Fistulas: A Retrospective Case Series..............................................................................................................29
Vijaya Sahu, C.D.Sahu, Nidhi Pandey, Bhagyashri Bhutada
Cross Sectional Study on Awareness About Eye Banking in Moradabad (India)..........................................35
Archana Chaudhary, Maitri Paul, Ashi Khurana, Lokesh Chauhan
Retrobulbar Amphotericin B in Mucormycosis: A Ray of Hope ...................................................................40
Shalini Mohan, Kunal Sahai, Namrata Patel, Tejasvini Chandra, Priyesh Kumar
Effects Of Long-Term Use of Topical Antiglaucoma Drugs On Ocular Surface
: A Cross Sectional Study.................................................................................................................................45
Aparajita Richhariya, Anshu Sahai, Mohammad Abid Shamshad, Pukhrambam
Ratan Kumar, Maryem Ansari
Health Literacy on Cataract and Its Treatment Options Among Patients with Operable Cataract: A Cross
Sectional Study from Moradabad (India)......................................................................................................50
Richa Gupta, Akansha Gupta, Mossab Omair, Lokesh Chauhan, Pradeep Agarwal, Ashi Khurana
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DJO Vol. 32, No. 3, January-March 2022
Case Reports
A Misleading Orbital Cystic Lesion..................................................................................................................55
Shruthi Tara, Shraddha Shah
Congenital Combined Eyelid Imbrication with Congenital Floppy Eyelid Syndrome-
A Rare Case Report.........................................................................................................................................58
Anuradha, Param Harsh, Jeevitha Periyakaruppan, Divya Dhiman
Stage 3 Retinopathy of Prematurity in a Child with Lipemia Retinalis..........................................................61
Ritesh Verma, Manisha Rathi, Sumit Sachdeva, Jitender Phogat, Sakshi Lochab
Vascular Occlusions triggered post Covid-19 infection...................................................................................63
Dhaivat Shah, Manan Solanki Shams Tabrez, Rinal Pandit, Devanshi Dalal
Photo Essay
Cryopreserved Amniotic Membrane in The Management of Persistent Epithelial Defect...........................67
Rajiv Garg, Siddharth Madan
Corneal Laceration Repair!.............................................................................................................................69
Prateek Jain, Anshuman Pattnaik
Isolated Co-Existence of Cerulean and Sutural Cataract................................................................................71
Cheau Wei, Chin
Leber’s Hereditary Optic Neuropathy: A Case Misinterpreted As Optic Neuritis..........................................72
Dhaivat Shah, Tina Damani, Shirali Gokharu, Akshar Soni
PG Snippets
A Brief About Hess and Lees Charting............................................................................................................74
Aakanksha Raghuvanshi, Rishabh Sah, Deepanshu, Subhash Dadeya
Omnibus Humanus (Masters, Change makers, Out of box thoughts)
Through The Eyes of An Ophthalmologist......................................................................................................79
Anju Sharma
Letter to Editor
A battle within the war - Mucormycosis: The Black Fungus Disease in India During COVID -19.....................81
Sujeeth Modaboyina, Mandeep S Bajaj, Sahil Agrawal, Deepsekhar Das
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DJO Vol. 32, No. 3, January-March 2022
Theme Article
Drugs Used in Ocular Local Anaesthesia: An Overview..................................................................................83
Anam Ansari, Priyanka Gupta, Siddharth Madan
Ocular Effects of Systemic Medications..........................................................................................................87
Divya Jain
Anti VEFG Agents In Retinal Diseases.............................................................................................................93
Khushboo Chawla
Vital Stains in Retina and Vitreous.................................................................................................................97
Shreyangshi Dipta, Shruti Bhattacharya, Khushboo Chawla
Biologics in Oculoplasty.................................................................................................................................100
Priyanka Golhait, Gaurav Singh
An Overview of Topical Immunomodulators used in Ophthalmology........................................................104
Pranita Sahay, Devesh Kumawat
Cover Image
Difficulties and Side Effect with Eye Drop Instillation
Kirti Singh, Khushboo Chawla
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DJO Vol. 32, No. 3, January-March 2022
DOS Executive Members 2021-2022
DOS Office Bearers
Dr. Pawan Goyal Dr. Rajendra Prasad Dr. Jitender Singh Bhalla Dr. Sandhya Makhija
President Vice President Secretary Joint Secretary
Dr. Alkesh Chaudhary Dr. Kirti Singh Dr. Jitender Bali
Treasurer Editor Library Officer
Executive Members
Dr. O. P. Anand Dr. Gagan Bhatia Dr. Vivek Gupta Dr. Vivek Kumar Jain
Dr. Prafulla Maharanaa Dr. Amar Pujari Dr. Bhupesh Singh Dr. Pankaj Varshney
DOS Representative to AIOS Ex-Officio Members
Dr. J.S. Titiyal Dr. M. Vanathi Dr. Subhash ChaDnrd. SDuabdheaysah C. Dadeya Dr. Namrata Sharma
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DJO Vol. 32, No. 3, January-March 2022
Editorial
From the Editor’s Desk
Empathy and Human Connect: Winning Combination for i- Drugs Adherence
“Doctors put drugs of which they know little into bodies of which they know less for diseases of which they know nothing
at all.” Voltaire’s cynicism has its roots in some truth especially when it comes to understanding of the bodies which house
the eyes of our patients.
Trained as surgeons, ophthalmologists focus on repairing and restoring damaged anatomy-physiology. This often makes
them lose touch with the human housing our surgical battle field. Often it is a professional necessity to detach from the
patient on whom we operate, however more often it is reflex derived from our emphasis on technology, precision and lack
of empathy.
Ophthalmology has evolved with large treasure trove of drugs and eye drops to choose from. Listening to patients,
understanding their systemic comorbidities, looking at their family dynamics, their needs, disabilities and inabilities, all is
often ignored in our zeal to deliver vision to our eyes. We forget a basic truth, eyes are hosted by a body with an imperfect
mind, often ailing spirit and accompanied by unwilling family members. Glaucoma being the established rogue disease
causing maximal visual casualty is very vulnerable to this, as most patients fall in the category of not being able to take
care of themselves and yet require multiple eye drop usage. The cover picture of this issue, details few of these difficulties.
For our eye drops to be effective, we need to address the patient aspect of the eyes we treat. We need empathy so as to ensure
adherence to medication. Most adherence studies corroborate poor adherence to long term medications, glaucoma being
prime example. Reports state 93% self-reported ease of instilling anti glaucoma drops, with actual correct administration
being only 31%. (Stone JL et al. An objective evaluation of eyedrop instillation in patients with glaucoma. Arch Ophthalmol.
2009;127(6):732–736).)
Where does my patient live, can she travel for health care, is she able to comprehend the need for lifelong medication without
perceiving any visual improvement (glaucoma) , will she go for a refill from the ever friendly chemist or will she come back
to me, is she better off with surgery or will her drops maintain functional vision for her lifetime, will she be able to afford the
drops ? The questions are many, the answers often incomplete , nonetheless this checklist of queries would need to be tackled
during patient doctor encounters, if a successful rapport and effective medication regimen is to be established. My doctor
listens to me, cares for me, is often the highest accolade a patient can pay , however few of us get this honour.
Digital munificence of current century has resulted in a digital divide between emotive and cognitive aspects of patient
doctor relationship. This is in part, the villain of the distrust and mala fide pattern prevalent in patient doctor relationship
of today.
This issue with its focus on ophthalmic drugs and guest editorial of rational use of drugs, seeks to incite thoughts on when
too much is not good. Optimization and connect with the human aspect of the patient is the answer for continued vision of
the eyes entrusted to us, while maintaining trust during tryst with our professions.
Prof. Kirti Singh
MD, DNB, FRCS, FAIMER, DHA
Editor Delhi Journal Ophthalmology
Dir Professor Glaucoma Service & Director Guru Nanak Eye Centre,
Maulana Azad Medical College, New Delhi
State Program Officer, NPCBVI Delhi Division
DOI : http://dx.doi.org/10.7869/djo732.
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DJO Vol. 32, No. 3, January-March 2022
Guest Editorial
Abha Gour, Virender S. Sangwan
Detrimental effects of irrational drug therapy on the ocular surface
The most important guiding principle for most doctors remains do no harm, which in this case is essential to maintain the
delicate balance of the ocular surface. With increasing access to healthcare and the ease of application of topical medication
they tend to be overused with deleterious effects in the long run. Likewise, topical medications for chronic conditions like
glaucoma also contribute to the imbalance in the ocular microbiome. Here we intend to highlight these issues and also
discuss their management.
The ocular surface is also exposed to various environmental factors due to the nature of its function and anatomical
location. Any disruption in the structure can hamper its functioning and cause damage to the ocular surface. The disorders
associated with the ocular surface which includes the cornea, conjunctiva, eyelids and the lacrimal glands are classified
as ocular surface disorders (OSD).1 Clinically, there is a high prevalence of OSD but they remain undiagnosed because of
the insufficient understanding of its symptoms and improper evaluation. These disorders include Dry Eye Disease (DED),
Allergic eye diseases (AED), blepharitis, meibomian gland dysfunction (MGD), Keratitis, chemical and thermal burns etc.
Such diseases can have a severe effect on the eye-sight and in chronic cases, might lead to blindness.
The metabolites of the topical medications generally get deposited in the conjunctival and corneal epithelial basement
membrane hence disrupting the surface immune response and result in inflammation of the ocular surface. Most commonly
responsible for this are the chronically used medications and preservatives
Glaucoma medication
Glaucoma is the second highest cause of blindness across the world and has been predicted to affect 79.6 million people by
year 2020. The initial treatment of glaucoma involves use of topical medications as therapy which results in ocular surface
diseases in 50-60% of the patients.2 Currently used therapies for glaucoma involve the use of prostaglandin analogs, beta-
adrenergic antagonists, alpha-adrenergic agonists, and topical carbonic anhydrase inhibitors. The presence of different
types of preservatives or even the active part of the medication leads to development or worsening of OSD symptoms.2
Various studies have shown that as the need for required glaucoma medication increases, there is a rise in the incidence and
severity of dry eyes. All the above-mentioned classes of medications have specific adverse effects on the eye and corneal
surface. A rise in the incidence and severity of dysfunctional obstructive meibomian gland is observed due to consumption
of prostaglandin analogues.3 The blocking of beta receptors in the lacrimal glands by the use of Beta blockers also leads to
a fall in the basal tear turnover rate.4 Brimonidine tartrate, an alpha- adrenergic agonist shows a rise in the prevalence of
ocular allergies in comparison to other prescribed topical medications.5 In addition to this, due to the use of dorzolamide,
a carbonic anhydrase inhibitor, an increase in the corneal thickness has been observed.6 The patients suffering from any
pre-existing OSD experience exacerbation of symptoms such as burning, irritation, itching and fall in visual acuity after
consuming topical therapy. In addition to this, patients of primary open angle glaucoma (POAG) that are untreated are
partly at an increased risk towards OSD as a 22% fall in basal tear turnover rate is observed when compared to healthy
individuals.7 Also, subconjunctival glaucoma surgeries have an increased failure rate in patients with ocular surface
disorders.
Other than the prolonged use of topical medication for management of glaucoma, increased intraocular pressure and
inadequate functioning of the endothelial pump mechanism also contribute to the disruption in the ocular surface
microenvironment.
Preservatives
For prevention of microbial contamination, preservatives are commonly used in lowest possible concentrations in medications.
Currently, preservatives added in medications for glaucoma comprise of Benzalkonium chloride (BAK), stabilized oxychloro
complex added in Alphagan P, sofZia preservatives added in Travatan Z and formulations of Polyquaternium-1 used in
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DJO Vol. 32, No. 3, January-March 2022
Travatan formulations.8,9 Usually these added preservatives target the cell walls of bacteria and also improve the penetration
of drugs within cornea. The most commonly used preservative is BAK, which leads to the initiation and worsening of OSD
by the destabilization of goblet cells and the tear film. BAK preservatives affect the conjunctival epithelium by inducing
squamous metaplasia that leads to the disruption of corneal epithelium due to loss of epithelial cell density and an increase
in activation of stromal keratocytes.10 Various animal studies have concluded that ocular surface effects of BAK are
concentration dependent such that its higher concentrations lead to more corneal damage as well as infiltration of the
conjunctiva.11 Even though BAK shows higher level of ocular surface toxicity, it shows the highest effectiveness for the
inhibition of microbial growth in medicines when compared to the newer preservatives.12
Topical anesthetic abuse
In ophthalmology, topical anesthetic drugs find a wide range of application for diagnosis and surgeries. These anesthetics
include proparacaine, tetracaine, lidocaine and benoxinate cocaine that function by blocking of sodium channels within
the neuronal axons which keeps the brain from detection of pain stimuli.13 These drugs are usually well-tolerated but can
cause severe toxic effects when abused. The ocular surface is commonly affected due to the abuse of such anesthetics as they
can cause permanent damage to the corneal surface by deep infiltration of cornea, corneal ulceration and loss of visual
acuity.14 Punctuate corneal epithelial erosions are observed during routine administration of topical anesthetics along with
evidence of epithelial toxicity. It can be seen in the form of corneal drying due to the loss of corneal sensations leading to
a fall in blinking rate and tear production.15 Migration of corneal epithelial cells is inhibited due to such anesthetics which
leads to impaired healing and chronic defects within the eye. In addition to this, anesthetic toxicity can show symptoms that
mimic other conditions like neurotrophic ulcers and refractory corneal lesions. There have been various reports of corneal
thinning, perforation and ulceration due to abuse of topical anesthetics.16
NSAIDs
Topical nonsteroidal anti-inflammatory drugs (NSAIDs) are usually used against ocular inflammation that is triggered due
to diseases such as allergic conjunctivitis, and in the long term management of cystoid macular edema post cataract surgery.
NSAIDs when used over longer periods tend to hamper corneal epithelial cell turn over causing corneal melts which though
rare is one of the most serious consequences. The deleterious effect of the NSAIDs is exacerbated by previous existing tear
film instability and systemic diseases like diabetes, hence their use post cataract surgery must be supported by adequate
ocular surface stabilization.
Medications for red eye
Multiple medications containing phenylephrine or naphazoline are household names for the treatment of a
red eye commonly due to some minor irritation and allergy. These may be prescribed by the local chemist and
non-healthcare professionals as well, and act by vasoconstriction and reducing the ocular surface blood flow.
Prolonged use of these vasoconstrictors also causes a block in the protective inflammatory mediators to the surface.
These are also known to cause CNS depression in infants and when left in their reach can have serious consequences
Corneal deposits
In our country the inadvertent use of topical antibiotics is exacerbated by the easy availability without the need for an
evaluation by the ophthalmologist. Most used are the fluroquinalones amongst which ciprofloxacin is known to cause
corneal deposits. Surface inflammation associated with an epithelial defect and instability in the surface tear film lead to
crystallization of the drug compound on the surface forming deposits. The early phase is usually reversible with stopping the
offending agent, but chronic conditions may need a mechanical scraping or a phototherapeutic keratectomy.
Effect of systemic medication
Anti-depressants
According to National Mental Health Survey of India in 2015-16, one in every twenty Indians are subject to depression.17 One
of the commonly prescribed anti-depressants Selective Serotonin Reuptake Inhibitors (SSRIs)18 show the highest tendency
towards development of (DED). SSRIs increases the levels of serotonin cause different ocular side effects specifically in tears
that cause modulation of corneal nociceptor sensitization, reduced corneal nerve sensitivity, reflexes of lacrimal glands and
tear film.19 The use of SSRIs and TCAs particularly increase the propensity of dry eye disease as it decreases the secretions
of the lacrimal glands that may manifest into photophobia 20
Antipsychotics
Psychotropic drugs have been under researched with the aspect of having various ocular side effects due to drug toxicity and
their effect on specific body mechanisms. These drugs have a potential to induce various adverse disorders which include
keratoconjunctival issues, uveal tracts diseases, angle-closure glaucoma, cataract, retinopathy, depositions on cornea and
various ocular surface side effects.18 Clozapine used in the treatment of Schizophrenia reduces the activity of the lacrimal
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DJO Vol. 32, No. 3, January-March 2022
glands and mucous secreting glands, and also causes morphological changes in the thickness of the cornea due to its anti-
cholinergic and anti-dopaminergic effects.21,22,23
Chemotherapeutic drugs
Chemo therapeutic drugs have been an effective conventional treatment for cancer that is a global health issue leading to
millions of deaths worldwide due abnormal and uncontrollable growth of cells within the body. The chemotherapeutic drugs
act as cytotoxic agents that interfere with the cellular process of DNA synthesis and mitosis resulting in cell death and reduced
tumor load.24 Clinically eye-lid scarring and dysfunction of meibomian glands due to different cytotoxic and inflammatory
reactions of these drugs within the body has also been evidenced.25 Chronic exposure to these drugs causes inflammation of
mucosal membrane lining of the lacrimal system causing changes in the tear film.26 In addition to this, for the anti-cancer
treatment to cause ocular surface toxicity, the dosage, deliver system of the drug, duration of the treatment potentially affects
the extent of toxicity, which sometimes also results in discontinuing the chemo therapeutic drug, contrastingly some studies
gave no evidence of ocular toxicity due to dose response hence more research is required for investigation of ocular toxicities
dependent on drug regimens.27
Clinical features of disease
Ocular drug toxicity may present a very varied picture with multiple overlapping nonspecific signs and symptoms. Mild
cases may present with a red inflamed eye whereas severe cases have more extensive involvement of the entire ocular surface
from eyelid dermatitis, squamous blepharitis, chemosis and punctate keratitis to corneal ulceration and non-healing corneal
epithelial defects
The three major causes of the reaction remain
a) Hypersensitivity: allergic reaction to the active component/ preservative of the drug
b) DED: chronic use of the medication tends to cause instability in the composition of the tear film.
c) Direct epithelial damage: due to chronic and cumulative use of medication
As discussed under the causative topical drugs the clinical picture is more often overlapping, with the most common complaint
being a red eye, and significant increase in the conjunctival surface inflammatory mediators such as interleukins in most
cases. Most of the symptoms can be attributed to damage and loss of the conjunctival and corneal surface goblet cells.
Damage to the lacrimal functional unit due to many of the systemic drugs causes symptoms of dry eye disease with damage to
the cell surface associated transmembrane mucins, which in turn has a detrimental effect of the ocular surface. Maintenance
of an intact mucosal barrier is also important to maintain and adequate epithelial function, which when hampered causes
superficial punctate keratitis and non-healing epithelial defects, and increased penetrance of the damaging compound.
Management
The management involves recognizing the problem, followed by the withdrawal of the agent which at times is difficult
to pinpoint because of the multitude of the topicals being used. This is mostly seen when the diagnosis of the ocular
ailment is unsure and a broader base therapy is prescribed, like in the case of infective keratitis where the exact causative
microorganism is unknown.
The use of preservatives to prevent the contamination of the active drug compound needs to be considered and preservative
free medications should be used for more chronic ailments like glaucoma.In some cases, the active compound itself may
be causing a detrimental effect when used chronically and hence surgical intervention when appropriate may need to be
considered
The management broadly involves breaking the cycle of surface inflammation by removing the inciting factor and adding
mild surface acting topical steroids which in most cases provides immediate relief.
The DEWS committee has very well described targeted therapy for symptoms of dry eye disease based on the severity of
symptoms. Mild cases respond to preservative free lubricants alone whereas the more severe cases may need more targeted
therapy. Lid hygiene and warm compresses are important to manage the blepharitis component, and topical steroids to
reduce the surface inflammation. The use of bandage contact lens for moderate to severe cases provides relief to the patient
and helps in epithelial healing. Very severe cases with non-epithelizing defects may need amniotic membrane transplant and
the use of systemic therapy as well.
The goal of management remains to restore the tear film and the ocular surface, the first step in which remains removing the
inciting factor, and use of more targeted therapy rather than cocktail medications.
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DJO Vol. 32, No. 3, January-March 2022
References
1. Khanna, R.C., Ocular surface disorders. Community eye health, 2017. 30(99): p. S1-S2.
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25(9): p. 770-4.
4. Martone, G., et al., An in vivo confocal microscopy analysis of effects of topical antiglaucoma therapy with preservative on corneal
innervation and morphology. Am J Ophthalmol, 2009. 147(4): p. 725-735.e1.
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7. Skalicky, S.E., I. Goldberg, and P. McCluskey, Ocular surface disease and quality of life in patients with glaucoma. Am J Ophthalmol, 2012.
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treated patients with open-angle glaucoma. Clin Ophthalmol, 2012. 6: p. 103-9.
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Cornea, 2004. 23(5): p. 490-6.
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travoprost with the sofZia preservative system. BMC Ophthalmol, 2011. 11: p. 8.
13. Bacon, D.R., Seeing an Anesthetic Revolution: Ocular Anesthesia in History. Ophthalmology Clinics, 2006. 19(2): p. 151-154.
14. Rosenwasser, G.O., et al., Topical anesthetic abuse. Ophthalmology, 1990. 97(8): p. 967-72.
15. Erdem, E., et al., Topical anesthetic eye drops abuse: are we aware of the danger? Cutan Ocul Toxicol, 2013. 32(3): p. 189-93.
16. McGee, H.T. and F.W. Fraunfelder, Toxicities of topical ophthalmic anesthetics. Expert Opin Drug Saf, 2007. 6(6): p. 637-40.
17. Narayanan, V., Ocular Adverse Effects of Antidepressants – Need for an Ophthalmic Screening and Follow up Protocol. Ophthalmology
Research: An International Journal, 2019: p. 1-6.
18. Richa, S. and J.-C. Yazbek, Ocular Adverse Effects of Common Psychotropic Agents: A Review. CNS drugs, 2010. 24: p. 501-26.
19. Acan, D. and P. Kurtgoz, Influence of selective serotonin reuptake inhibitors on ocular surface. Clin Exp Optom, 2017. 100(1): p. 83-86.
20. Zhang, X., et al., Selective Serotonin Reuptake Inhibitors Aggravate Depression-Associated Dry Eye Via Activating the NF-κB Pathway.
Investigative Ophthalmology & Visual Science, 2019. 60(1): p. 407-419.
21. Miyamoto, S., et al., Treatments for schizophrenia: a critical review of pharmacology and mechanisms of action of antipsychotic drugs. Mol
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22. Pramanik, T. and R. Ghising, Salivation induced better lacrimal gland function in dry eyes. Nepal Med Coll J, 2009. 11(4): p. 258-60.
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24. Chiang, J.C.B., et al., The impact of anticancer drugs on the ocular surface. The Ocular Surface, 2020. 18(3): p. 403-417.
25. Aldred, E.M., C. Buck, and K. Vall, Chapter 19 - Pharmacodynamics: How drugs elicit a physiological effect, in Pharmacology, E.M. Aldred,
C. Buck, and K. Vall, Editors. 2009, Churchill Livingstone: Edinburgh. p. 137-143.
26. Karamitsos, A., et al., Ocular surface and tear film abnormalities in women under adjuvant chemotherapy for breast cancer with the
5-Fluorouracil, Epirubicin and Cyclophosphamide (FEC) regimen. Hippokratia, 2013. 17(2): p. 120-5.
27. Stevens, A. and D. Spooner, Lacrimal duct stenosis and other ocular toxicity associated with adjuvant cyclophosphamide, methotrexate and
5-fluorouracil combination chemotherapy for early stage breast cancer. Clin Oncol (R Coll Radiol), 2001. 13(6): p. 438-40.
28. Martin, M., et al., Doxorubicin in combination with fluorouracil and cyclophosphamide (i.v. FAC regimen, day 1, 21) versus methotrexate in
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Dr. Virender S. Sangwan (MS)
Department of Cornea,
Anterior Segment and Uveitis,
Dr. Shroff’s Charity Eye Hospital,
New Delhi, India
DOI : http://dx.doi.org/10.7869/djo733.
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DJO Vol. 32, No. 3, January-March 2022
Review Article
Paucity and Dearth of Eye Health Education Material (EHEM)
In Hindi Language on Internet
Abha Shukla, Divya Rana, Kirti Chhabra, Rashmi Kujur
Department of Ophthalmology, Gajra Raja Medical College, Gwalior, Madhya Pradesh, India.
Aim: The goal of this study is to assess the availability of literature (EHEM) in Hindi language on internet pertaining to eye health
education and eye diseases. Today internet is considered as reliable and important source for getting any kind of information
by all age groups. People also use it as a mode for collecting knowledge about health problems. Eye health education material
(EHEM) is plenty on internet but only in English language. People can better understand EHEM in Hindi. As a part of our mission
to fight against blindness it is our responsibility to prepare EHEM in simple native languages and make it easily available on
Abstract internet. This will be a major step towards improving health literacy of our country. An extensive search for eye health-related
information in Hindi language on internet was done. All websites and the Pub Med literature database searched for related
work. The information related to eye and eye diseases in Hindi on internet is insufficient for improving the health literacy of
our population. Internet is brimming with knowledge imparting sites for eye health care not only in English but in many more
foreign languages. Scanty material is available for our Hindi understanding people, this significant gaps needs to be addressed
for further development of an effective health information system in India.
Delhi J Ophthalmol 2022; 32; 11-14; Doi http://dx.doi.org/10.7869/djo.734
Keywords: Hindi, Health Education, Eye Health Education, Internet, Health Literacy
Introduction and developing life skills which are conducive to individual
and community health.5 The skills of health professionals,
The Internet offers widespread access to all types of the media, and government and private sector agencies to
information including health information.1 The fast Internet provide health information in a manner appropriate for their
access in our country has opened up new possibilities. Eye audience are as important as an individual’s skill because
health information is plentiful on Internet but majority of the interactions between layman and professionals influence
the sites provide information only in English language. the health literacy of the individual and the society.6
Searching and obtaining reliable information in Hindi is
very difficult. No country could have original development Education of consumers is beneficial as a well-informed
using a foreign language neither can it establish its own society is an essential infrastructure of a health system.
identity in the field. Thus in order to give benefit of good Paradoxically, there is voluminous literature for health care
health to common people, it is important that EHEM should professionals but very little for patients and for the needs of
be made available in Hindi. general public.
Blindness in our country cannot be attributed to clinical Vision of other countries about health education: Different
causes alone because inspite of good facilities and countries have addressed the need of their people by making
competent resources for treatment, we do witness cases of EHEM available not only in official language but also in
lens induced glaucoma, amblyopia, corneal ulcers, opacities, different local languages.7
misuse of steroid eye drops, absolute glaucoma, advance
diabetic eye disease and many more . Various studies have Role of Internet in health Education: The internet is a
also shown that people in our country have poor awareness powerful tool for connecting people to information, ideas,
about eye diseases.2,3 Illiteracy and ignorance of diseases, its resources, services, and other people. In last few years,
risk factors and treatment contribute to increase in number internet has grown as an important tool for health education
of people not being able to access the health care. Creating in many countries due to its ability to deeply engage large
public awareness is necessary as health education not only numbers of targeted individuals and communities over a
imparts knowledge about the symptoms of diseases but sustained period of time.8
also about the various treatment options, comply with the
treatment process and understand the necessity of follow But it is being neglected in our country. India is now third in
ups. This will definitely help in reducing the burden of the world in number of internet users, behind only the U.S
blindness. and China.9 Youth in India is getting hooked on to Internet.10
If used properly, it can help us to spread health literacy
Health literacy: is the ability to obtain, read, understand economically to wide spread population in small time.11
and use healthcare information to make appropriate health Readymade and easily available material will not only be
decisions and follow instructions for treatment.4 used by immediate users to improve their knowledge but
can be used by media people, NGOs, practitioners and the
Health education: is one way by which we can improve health workers for educating their target group. We need
health literacy. The World Health Organization defined websites not only in Hindi language but also in numerous
Health Education as consciously constructed opportunities other Indian languages so that people can be empowered to
for learning involving some form of communication designed take responsibility of their own health.
to improve health literacy, including improving knowledge,
E-ISSN: 2454-2784 P-ISSN: 0972-0200 11 Delhi Journal of Ophthalmology
DJO Vol. 32, No. 3, January-March 2022
Material And Methods Discussion
An extensive search with the key words was done on internet Importance of language in Health education:
(on all websites and the database) for eye health education Language barriers significantly affect quality of care in the
and related information in Hindi. Various sites of agencies health care system.12
working in the field of eye care like government, private,
NGOs, various ophthalmic societies of different states, “In the 2001 Indian census, 258 million (258,000,000)
private and government eye hospital, charitable hospital people in India reported Hindi to be their native language.
were searched extensively for EHEM in Hindi. As per the Article 343 (1) of the Indian constitution "The
official language of the Union shall be Hindi. Hindi is
Results the native language of most people living in Delhi, Uttar
Pradesh, Uttarakhand, Chhattisgarh, Himachal Pradesh,
There is poor availability of material related to eye health Chandigarh, Bihar, Jharkhand, Madhya Pradesh, Haryana,
education in Hindi language for the public on government and Rajasthan.13 Health literacy and literacy are closely
and private health sites who are the providers of large related but not identical. Health literacy is influenced by the
proportion of eye health services in India. Only few sites language we speak. The NHP (National Health Portal) has
(Table 1,2) showed some EHEM. Majority of the information been launched with the domain name for NHP (nhp.gov.in
was available at foreign sites with almost negligible or nhp.org.in) but still sufficient information is not available
information at Indian sites. Out of about 58 ophthalmic in Hindi language.14
societies and other optician and pharmaceutical sites, none
has EHEM available in Hindi or in any other local language. Efforts by IT sector to improve Hindi language usage on
There is no study reported on the availability of Eye Health the internet: We are a country of billion today with 52 million
Education Material (EHEM) for public in Hindi language. active users of internet, that will increase to 500 million by
2017.15 Hindi is one of the seven languages of India that can
Table 1: Sources That Yield Essential Eye Health Information In Hindi be used to make web addresses.16
Resource Name Links Google is also focusing on Hindi. It has Launched Indian
www.onlymyhealth.com Language Internet Alliance the (ILIA), hindiweb.com,
Eye problem in Hindi: improved version of the Voice Search in Hindi ,the voice-
vka[ksatkudkjh – y{k.k ..... http://www.nlm.nih.gov/ assistant had got an Indian accent, faster Hindi keyboard ,
Health Information in Hindi medlineplus/languages fifteen Hindi font families. Now search in Hindi is gaining
(fgUnh): MedlinePlus https://www.healthinfotranslations. more focus, and better features.17 With increase in mobile
org/pdfDocs/Cataract and internet users in India now non-English speakers are
Cataract - Hindi - Health www.ramdevmedicine.com also availing this platform. Health programme promoters
Information Translations have to make their online experience as easy as the English
nirog.info speakers.
Eye Problems - Baba Ramdev
Medicine www.healthinfotranslations.org/ What is the Pressing need to make free and easy availability
language/hindi/95723 of EHEM in Hindi on Internet?
Nirog: Health Information in The first war against blindness has been successfully
Hindi - Eyes | vka[ksa https://www.rnib.org.uk fought by launching National Programme for Control of
Blindness (NPCB) in 1976 even prior to the World Health
Hindi - Health Information days.jagranjunction.com/.../ Organization.18 By strengthening the infrastructure of eye
Translations from ... international-eye-donation care services in the government, voluntary and private
sectors, cataract is adequately addressed in many parts of
Eye condition information in en.wikipedia.org/wiki country.19 Now a strong foundation is ready to take on the
other languages | RNIB future challenges i.e. the second battle against blindness
http://www.patient.co.uk/doctor/The- due to other conditions more complicated than cataract.
–f"Vnkufnol: fdlhdhftanxhesadjें Eyes-In-Systemic-Disease.htm Diabetic retinopathy, glaucoma, uncorrected refractive
error, age-related macular degeneration etc. are posing
Eye disease - Wikipedia, the free growing threats to vision of the millions .While blindness
encyclopaedia due to cataract is curable by a simple day care surgical
intervention, other conditions encompass a multitude of
Eye Problems - Patient.co.uk problems that are asymptomatic at the treatable stage but
when a person presents for treatment with loss of vision, it
Table 2: Different countries’ dedicated sites for eye health education is often too late for intervention. These conditions can be
treated and even prevented in some cases, only by treating
Resource Name Links them before it is too late. Without sufficient education and
www.nlm.nih.gov/medlineplus/ awareness, millions of people do not realize that they have a
Health Information in Hindi f gUnh : condition that needs treatment, or they do not know what to
MedlinePlus languages/hind do. To address this, widespread easily-understandable eyes
http://www. health education program is needed.20 To rationalize the
Health Information Translations
healthinfotranslations.com/
Materials in Hindi — Health here.doh.wa.gov
Education Resource Exchange ...
en.wikipedia.org/wiki
Internet Links to Health Education
in Your Language http://www.
bridginghealthcaregaps.com/.
Eye disease - Wikipedia, the free
encyclopaedia https://www.patient.co.uk/
Eye Problems - Patient.co.uk
Symptom Checker, Health
Information and Medicines Guide
E-ISSN: 2454-2784 P-ISSN: 0972-0200 12 www.djo.org.in
DJO Vol. 32, No. 3, January-March 2022
expectations from the providers by the clients, patients and Now it’s our turn to show strong commitment for improving
relatives about the visual outcome in these conditions and in health literacy. All cadres who are involved in the eye care,
cataract associated with them, we have to create appropriate should prepare various type of eye health education material
new materials in the language of the target audience rather in Hindi and their local language to improve health literacy
than translating a document that already exists in English. and fight against blindness in our country.
Steps To Be Taken Now References
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information and improving health literacy we need to resource of health information by patients: a clinic-based study
develop various strategies, guidelines and models. in the Indian population. J Postgrad Med. 2005;51:116-8.
Although primary responsibility for improving health
literacy lies with public health and eye professionals, 2. Dandona R, Dandona L, John RK, McCarty CA, Rao GN.
the healthcare and public health systems but no single Awareness of diseases in an urban population in southern
group or organization can address this issue on its own, India. Bull World Health Organ.2001; 79:96-102.
initiatives must be taken by all the sectors in making a
proper system for collecting, compiling, analyzing and 3 .Rajani Kadri. Awareness of Diabetic and hypertensive eye
displaying the information related to various eye conditions disease in Public. Int J Biol Med Res.2011; 2: 435-533.
and diseases, risk factors and management on internet. A
web based National Health information and management 4. Lorraine Wallace. Patients’ health literacy skills: the missing
system (NHIMS) or eye health education program can be demographic variable in primary care research. Ann Fam Med.
established. 2006; 4: 85-6.
Proper EHEM should be prepared in simple and most 5. World Health Organization. (1998). List of Basic Terms. Health
popular language, which general public with average literacy Promotion Glossary. (pp. 4). Retrieved 2009 May 1, from http://
can understand. However, for this to happen , the website www.who.int/hpr/NPH/docs/hp_glossary_en.pdf
has to be designed and implemented properly. Users should
be able to find and read whatever they want to understand 6. U.S. Department of Health and Human Services, Office
and act appropriately. Though, multilingual websites are of Disease Prevention and Health Promotion. National
now being created and due to translation it is now possible Action Plan to Improve Health Literacy. Washington,
to get fairly correct and understandable version of the DC: Author.2010May. Available from: http://health.gov/
original content in Hindi. A bigger problem relates to the communication/hlactionplan/pdf/Health_Literacy_Action_
content in videos. It must be ensured that health information Plan.pdf
should not be incomplete or inaccurate. Periodic research
should be conducted to evaluate the perception of public, 7. Ann Morse. Language access: Helping Non-English speakers
change in the quality of life of individuals, and efficiency navigate health and human services.2003Jan.Available from:
of this system to spread the information. Based on the data www.ncsl.org/.../languagesvcs.pdf National Conference of
and the research findings, policy briefs should be prepared State Legislatures
along with suggestions to improve the material and revise
strategies through discussion with the technical committees 8. Jay M. Bernhardt, John Hubley. Health literacy Health
and decision makers. NHIMS will keep monitoring trends education and the Internet: the beginning of a revolution.
of information use and upgrading them time to time as per Oxford Journals Health Education Research2001;16 :643-45
evolving knowledge. Instead of being silent bystanders,
end users should be actively involved in decision making, 9. IAMAI. [Internet]. India To Cross 300 Million Internet
planning and provide feedback to the system.21 Users By Dec? 2014 Nov 19.Available from: http://www.
internetworldstats.com/asia/in.htm
One big step has already been taken by health ministry
by making a “people’s ministry accessible to the people’’ 10. IMRB. [Internet]. 45 Million Internet Users in India. Available
and by promoting use of Hindi in official work and on from: http://www.imrbint.com/old/media/45
the social media platform.22 Now government websites,
official documents and health-related standing committee 11. Internet and Mobile Association of India (IAMAI).[Internet]
materials are made available in Hindi language. Official Internet for rural India: 2010August. Available from: www.
accounts on Twitter, Facebook, Google, YouTube and blogs iamai.in/Upload/Research/internet_for_Rural_India_44.pdf
are prepared in Hindi and English languages. Websites
of health Ministry, National AIDS Control Organisation, 12. Hang Li, Yunbo Cao, Cong Li. Overcoming Language Barriers
AIIMS, Integrated Disease Surveillance Programme and the in the Internet Era - A Foreign Language Reading Assistance
directorate of health research agencies such as the National System. Microsoft Research, Asia, 5F Sigma Center, Beijing,
Centre for Disease Control and Indian Council for Medical China100080T, 2002Sept12.Technical Report: MSR-TR-2002-91
Research are now developed in Hindi language.
13. Census of India. 2001."Data by speakers of language" Available
from:http://www.censusindia.gov.in/Census_Data_2001/
Census_Data_Online/Language/gen_note.html
14. NHP (National Health Portal) INDIA. Available from: http://
www.nhp.gov.in/
15. Digital India - The DMTI Available from: thedmti.com/images/
Digital_India_2014.pdf
16. Sreejiraj Eluvangal. "URLs in 7 regional languages soon".
2011April 4 I: DNA. 2013 September 9. Available from:
http://www.dnaindia.com/india/report-urls-in-7-regional-
languages-soon-1528401
17. What Google's Indian Language Internet Alliance needs to
do. Available from: http://www.medianama.com/2014/11/223-
google-indian-language-internet-
18. Park K. Health programme in India. Park’s Textbook of
Preventive and Social medicine 20th ed. Jabalpur: Banarsidas
Bhanot Publishers; 2009.p. 375
19. Thulasiraj Ravilla Tackling Blindness in India: Have We Done
Enough? JIMSA 2010; 23:192-
20. J Hubley, C Gilbert. Eye health promotion and the prevention
of blindness in developing countries: critical issues. Br J
Ophthalmol 2006; 90:279–84.
21. Coulter A, Ellins J, Swain D. Assessing the quality of
E-ISSN: 2454-2784 P-ISSN: 0972-0200 13 Delhi Journal of Ophthalmology
DJO Vol. 32, No. 3, January-March 2022
information to support people in making decisions about their Cite This Article as: Abha Shukla, Divya Rana, Kirti
health and healthcare. Oxford: Picker Institute Europe, Nov Chhabra, Rashmi Kujur. Paucity and dearth of eye health
2006. http://www.pickereurope.org. education material (EHEM) in Hindi language on internet.
22. ChatterjeePritha. Health Ministry website in Hindi now, Delhi J Ophthalmol 2022; 32 (3): 11 - 14.
panel to oversee translation [Internet]. 2014 Aug 13, 2:59. Acknowledgments: Nil.
In: indianexpress.com New Delhi. Available from: http:// Conflict of interest: None declared
indianexpress.com/article/cities/delhi/health-ministry- Source of Funding: None
website-in-hindi-now-panel-to-oversee Open globe injury: Date of Submission: 16 Apr 2021
This is associated with full thickness involvement of the eye Date of Acceptance: 05 Mar 2022
wall. It is also of two types-
Address for correspondence
Divya Rana, Resident
Department of Ophthalmology,
Gajra Raja Medical College, Gwalior,
Madhya Pradesh, India.
E-mail: [email protected]
E-ISSN: 2454-2784 P-ISSN: 0972-0200 14 Quick Response Code
www.djo.org.in
DJO Vol. 32, No. 3, January-March 2022
Review Article
Steroid Induced Glaucoma: Dilemma Decoded
Shweta Tripathi1, Shalini Mohan2, Jatinder Singh Bhalla3, Kanika Jain3, Ashwini Kulkarni3
1Department of Ophthalmology, Indira Gandhi Eye Hospital and Research Centre, Lucknow, Uttar Pradesh, India.
2Department of Ophthalmology, Ganesh Shankar Vidyarthi Memorial (GSVM) Medical College, Kanpur, Uttar Pradesh, India.
3Department of Ophthalmology, Delhi Govt Deen Dayal Upadhyay Hospital (DDU) Hospital, New Delhi, India.
Abstract Topical and systemic steroids are used to treat many clinical conditions but its use is not without side effects. Amongst the
ocular side effects cataract and glaucoma are prominent. With the rising magnitude of glaucoma, it has become imperative to
understand the pathophysiology, risk factors and management of Steroid Induced Glaucoma. This review attempts to decode
the dilemma.
Delhi J Ophthalmol 2022; 32; 15-19; Doi http://dx.doi.org/10.7869/djo.735
Introduction Keywords: Steroid, Glaucoma, IOP
be lower in TM cells isolated from glaucomatous eyes.29
Corticosteroids are anti-inflammatory drugs commonly 2. Age: Older patients demonstrated higher risk of IOP
implicated in treatment of various ocular and systemic elevation development after administration of GC
conditions. Steroids are known to induce ocular hypertension eye drops. In children, the IOP elevation and possible
when administered by routes such as topical, periocular, resultant glaucomatous damage can have an earlier
systemic or inhalational routes.1 onset, be more severe at presentation, and progress
McLean2 reported a rise in IOP induced by systemic more rapidly compared to adults.29 IOP spike was most
administration of adrenocorticotrophic hormone (ACTH). commonly seen in children on topical steroid therapy for
After 4 years, Francois3 described the first case of elevated vernal keratoconjunctivitis. In a case series conducted
IOP induced by local administration of steroid (cortisone). in Singapore, forty-one of 145 (28.3%) patients with
In 1963, Becker and Mills4 demonstrated that patients who severe VKC developed a corticosteroid response, of
had glaucoma, or had been diagnosed as glaucoma suspects, which eight (5.5%) progressed to glaucoma.30
had marked IOP rises in response to several weeks’ exposure 3. Glaucoma diagnosis: An elevation in IOP in response
to topical corticosteroid. to corticosteroid therapy is more frequently observed in
Individuals who develop an increase in IOP following patients with POAG.
steroid use are referred to as "steroid responders". 4. Others: Connective tissue disease, high myopia, type I
Steroid responsiveness has been defined as follows over time diabetes mellitus and angle-recession glaucoma.
1) IOP increase > 5 mm Hg; Table 1: Risk factors for steroid induced glaucoma
2) IOP above 21 mmHg;
S.No. Risk Factor
3) IOP increase > 5 mm Hg with values above 24 mm Hg; 1 Increasing age
4) IOP increase > 10 mm Hg over baseline with clinical 2 Glaucoma suspects
significance, the last being the most widely accepted 3 Connective tissue disease9
definition.29
Armaly and Becker suggested three categories: for steroid 4 High myopia13-14
responders 4-8 5 Type I diabetes10
1.High responders (4 to 6% of the population) – developed 6 First-degree relative with primary open-angle glaucoma
an IOP greater than 31 mm Hg or a rise of more than 15 (POAG)5,11-12
mm Hg from baseline.
7 Angle recession glaucoma
2.Moderate responders (about 1/3 of the population)-
developed an IOP between 25-31 mm Hg or a rise of 6-15 Pathogenesis
mm Hg from baseline.
Steroid-induced glaucoma is open angle glaucoma with
3.Non-responders (about 2/3 of the population) – found to suggested mechanisms (Figure 1) for IOP elevation as
have an IOP less than 20 mm Hg or a rise of less than 6 follows:
mm Hg from baseline.
• Steroid causes stabilization of lysosomal membranes
Risk Factors and accumulation of polymerized glycosaminoglycans
(GAGs) in the trabecular meshwork which produce
The important risk factors for steroid induced glaucoma are biological edema leading to increased outflow
listed in (Table 1). resistance.15-17
1. Susceptibility: Individual differences in the risk • Glucocorticoids also increases the expression of
of steroid-induced IOP elevations are present. One extracellular matrix protein (fibronectin, GAGs,
possible explanation is the different expression of the 2 elastin, and laminin) within the trabecular meshwork
GR isoforms, GRa and GRb, GRb levels were found to cells which leads to increased trabecular meshwork
resistance.18-19
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DJO Vol. 32, No. 3, January-March 2022
• Corticosteroids cause inhibition of phagocytotic The persistent elevated IOP increases the risk of optic nerve
properties of endothelial cells lining the trabecular damage, leading to characteristic visual field changes similar
meshwork which leads to accumulation of aqueous to that with POAG.
debris.20
Other associated ocular findings are Posterior subcapsular
• Glucocorticoids have been shown to alter the trabecular cataract, red eye (Due to Uveitis /Vernal keratoconjunctivitis
meshwork cell morphology by causing an increase in for which the patient was on steroid therapy).
nuclear size and DNA content.21
Routes of Steroid Administration
• FKBP06–binding immunophilin FKBP51 mediates
nuclear transport of the human glucocorticoid receptor IOP elevation is caused by exogenous administration more
beta, which may play a role in increased glucocorticoid than endogenous administration.
responsiveness.22
Topical therapy: IOP rise after steroid therapy occurs more
• Glucocorticoid decreases the synthesis of frequently with topical administration as seen with eye
prostaglandin, which regulates the aqueous outflow.23 drops or ointments (Table 2).
• Several genes have been found to be associated with Periocular therapy: Prolonged duration of action in
both protective and damaging glucocorticoid-treated subconjunctival, subtenon, or retrobulbar injection of
trabecular meshwork cells.23 steroids is responsible for profound IOP spike.
• Myocilin (MYOC) is a gene identified as being Intravitreal therapy : (Table 3) IOP rise with intravitreal
induced by GC in the TM, other genes induced by GC depot steroid has been seen in a large percentage of
in the TM include serine protease inhibitor (alpha1- patients. Ozurdex is a slow-release intravitreal implant of
antichymotrypsin), pigment epithelium-derived factor dexamethasone used in the treatment of macular edema
(PEDF), cornea-derived transcript 6, prostaglandin secondary to vein occlusions and for the treatment of uveitis.
D-2 synthase, secretory leukocyte protease inhibitor Dexamethasone-induced ocular hypertension is transient
(SLP1), serum amyloid A2 (SAA2), angiopoietin-like 7 and is >10mmHg in 12.6% of patients. Dexamethasone
protein (ANGPTL7), serum amyloid A1 (SAA1), serpin is a more water-soluble steroid than triamcinolone or
peptidase inhibitor, clade A3 (SERPINA3), zinc finger fluocinolone acetonide, IOP spike is better controlled
and BTB domain containing 16 protein (ZBTB16), and without causing any ocular complications.45 Intravitreal
growth arrest specific protein 1 (GAS1).29 injection of triamcinolone can increase IOP by several mm
Hg in about 50% of patients, within 2 to 4 weeks after the
Figure 1: Various mechanisms of steroid induced glaucoma start of treatment.1
Clinical Features Potency of Steroids
The clinical features of corticosteroid induced glaucoma are IOP elevation or glaucoma can occur as a consequence
similar to those of POAG, with associated history of steroid of exogenous GC administration through the topical,
usage. intraocular, periocular, oral, intravenous, inhaled, nasal, and
transcutaneous routes(Table 2 , 3 and 4).29
Evaluation
• Visual acuity (VA) is likely to be normal except in
advanced cases.
• Tonometry prior to pachymetry, noting the time of day.
• Gonioscopy: It is key to diagnosis as it allows the clinician
to assess the status of the anterior segment angle, as
Steroid induced glaucoma is a secondary OAG.
• Optic disc examination for glaucomatous changes (see
below) should be performed with the pupils dilated,
provided gonioscopy does not show critically narrow
angles. Red-free light can be used to detect RNFL defects.
• Perimetry: to evaluate visual field changes in long
standing cases.
Differential Diagnosis
• Primary open angle glaucoma
• Normal tension glaucoma
• Juvenile open angle glaucoma
• Uveitic glaucoma
• Glaucomatocyclitic crisis
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DJO Vol. 32, No. 3, January-March 2022
Table 2: IOP changes in topically administered glucocorticoids29
Glucocorticoids Range of Duration of Dose Proportion of patients in whom
IOP increase administration
Dexamethasone Regimen hypertension developed (%)
Betamethasone (mmHg) (weeks)
Prednisolone 9-22 QID 45.8
Difluprednate 5-16 3-12 13
9-22 QID 44
Loteprednol etabonate 4-6 3
>10- >21 QID
Fluorometholone 2.5-12 0.8-16
Rimexolone <10- >10 BD
>10 QID 0-88.3
Clobetasone butyrate 2.9-6 >21 30
6.2- >10 QID -
1-6 BD
1.2-4 4-96
QID
5-6
QID
5.2-6
TDS, QID
6
Table 3: IOP changes in intra-vitreally administered glucocorticoids29
Route of Glucocorticoids Range Onset of Duration of Proportion of patients
administration of IOP
Dexamethasone (0.8 mg) increase hypertension administration in whom hypertension
IVT injections Triamcinolone acetonide (mm Hg)
(weeks) (months) developed (%)
IVT implants (4 mg) >21
Fluocinolone acetonide 1 day 1 45.8
>21 1-20 1-12 44
(0.59 mg; 2.1 mg; 0.2 >24
mg/d) 2-4 9-12 0-88.3
>10
Dexamethasone (0.7 mg) <30 1-12 2-12 0.8-16
<40
>10
>25
>35
Table 4: IOP changes in systemically administered glucocorticoids29
Route of administration Extent of IOP Period of Dose Proportion of patients
increase administration (weeks) regimen in whom hypertension
(mmHg)
developed (%)
Oral route 24-32 <1-11 months - 4.9
Intravenous route 0.8-1.6 1 day 3
Percutaneous route 32-39.4 2-5 years - 77.4
Inhalation route nasal 22-37 1-4 months 12-72 3-4.33
route
Management the lowest possible dose, administered by the safest
route, minimizing the risk of all potential adverse
“Prevention is the cure” when it comes to steroid induced effects. The corticosteroid response may take days
glaucoma. to weeks to resolve within a few days of cessation of
therapy.
• Discontinuation of the use of the steroid is the first line • Alternative corticosteroid formulations for topical
of management, acute rise of IOP normalizes within treatments can be chosen such as Fluoromethalone
days and chronic forms take 1 to 4 weeks after drug 0.1% which is claimed to have less effect on IOP.23
discontinuation. For certain conditions nonsteroidal anti-inflammatory
drugs (NSAIDs) can also be used.
• If IOP remains elevated anti-glaucoma medications or • For patients who need systemic corticosteroids, can
surgery may become necessary. be shifted to steroid sparing agents after consultation
with Physician.
• The duration of steroid therapy also appears to
influence the reversibility of the IOP elevation.25 Follow Up for Patients on Steroid Therapy
• If possible, the use of steroids can be avoided in A baseline measurement of IOP should be taken prior to
patients with pre-existing glaucoma as these are the Initiation of corticosteroid therapy. Patients on topical
individuals who are prone to steroid-responsiveness therapy should then have their IOP measured again 1-2
and may progress to significant visual loss i.e., End
stage of the disease.
• When steroid therapy is unavoidable, the choice of
drug should be of one that has a therapeutic effect at
E-ISSN: 2454-2784 P-ISSN: 0972-0200 17 Delhi Journal of Ophthalmology
DJO Vol. 32, No. 3, January-March 2022
weeks after initiation of treatment, then every 4 weeks for (like POAG, family history, diabetes mellitus, connective
2–3 months, then 6-monthly if therapy is to continue. tissue disorder, high myopia) along with detection of early
stage of corticosteroid induced high IOP to prevent them
Patients undergoing intravitreal triamcinolone should be from developing permanent visual loss. In most cases,
monitored for several months following the steroid injection, corticosteroid-induced glaucoma can be treated successfully
as various studies have reported a rise in IOP even after 100 by topical antiglaucoma therapy along with cessation of
days of treatment.24 corticosteroid therapy.
Ideally, patients requiring long-term systemic corticosteroid References
therapy should have glaucoma screening along with baseline
documentation of all parameters and should have their IOP 1. Phulke S, Kaushik S, Kaur S, Pandav SS. Steroid-induced
checked at 1, 3, and then every 6 months till the treatment is Glaucoma: An Avoidable Irreversible Blindness. J Curr Glaucoma
continued. Pract 2017;11(2):67-72. doi: 10.5005/jp-journals-l0028-1226. Epub
2017 Aug 5. PMID: 28924342; PMCID: PMC5577123.
Treatment
2. McLean JM. Use of ACTH and cortisone. Trans Am Ophthalmol
The treatment of steroid induced glaucoma is same as of Soc 1950; 48: 293–296.
Primary Open Angle Glaucoma.
3. Francois J. Cortisone et tension oculaire. Ann D’Oculist 1954;
Medical Management 187: 805.
• After cessation of steroid therapy, Beta Blockers are
first-line choice of drug for the condition. 4. Becker B, Mills DW. Corticosteroids and intraocular
• Prostaglandin Analogues are avoided in uveitic pressure. Arch Ophthalmol 1963; 70: 500–507 doi: 10.1001/
glaucomatous eyes. archopht.1963.00960050502012. PMID: 14078872.
• Carbonic anhydrase inhibitors &alpha agonist can be
used as a 2nd /3rd line of drug. 5. Becker b. intraocular pressure response to topical corticosteroids.
• Rho kinase inhibitors can also be added if the response Invest Ophthalmol. 1965 Apr;4:198-205. PMID: 14283013.
is poor to other anti-glaucoma medications.
6. Armaly mf. statistical attributes of the steroid hypertensive
Argon Laser Trabeculoplasty response in the clinically normal eye. i. the demonstration of
This treatment has been tried both before and after three levels of response. Invest Ophthalmol. 1965 Apr;4:187-97.
commencing corticosteroid therapy and has not been shown PMID: 14283012.
to be effective in preventing corticosteroid induced pressure
rises.26-27 7. Armaly MF. The heritable nature of dexamethasone-induced
ocular hypertension. Arch Ophthalmol. 1966 Jan;75(1):32-5. doi:
Filtration Surgery 10.1001/archopht.1966.00970050034007. PMID: 5900502.
Trabeculectomy stays the most efficient surgical treatment
of choice for cases who have persistently high IOP despite 8. Armaly MF. Inheritance of dexamethasone hypertension and
cessation of steroids and on maximum glaucoma. Arch Ophthalmol. 1967 Jun;77(6):747-51. doi: 10.1001/
medical therapy. archopht.1967.00980020749006. PMID: 6026182.
Excision of depot periocular or intraocular steroid may be 9. Gaston H, Absolon MJ, Thurtle OA, Sattar MA. Steroid
explanted in some patients.28 responsiveness in connective tissue diseases. Br J Ophthalmol.
1983 Jul;67(7):487-90. doi: 10.1136/bjo.67.7.487. PMID: 6860617;
Patient Education and Advice to Ophthalmologists PMCID: PMC1040100.
It is of utmost importance to advise patients against 10. Becker B. Diabetes mellitus and primary open-angle glaucoma.
unsupervised usage of over-the-counter steroids for slight The XXVII Edward Jackson Memorial Lecture. Am J Ophthalmol.
ocular discomfort and rather should seek consultation from 1971 Jan;71(1 Pt 1):1-16. doi: 10.1016/0002-9394(71)91088-9.
a certified ophthalmologist. PMID: 5099936.
Ophthalmologists especially the residents should be taught 11. Becker b, hahn ka. topical corticosteroids and heredity in primary
to use corticosteroids judiciously with appropriate tapering open-angle glaucoma. Am J Ophthalmol. 1964 Apr;57:543-51.
of the drug. Importance of regular IOP monitoring during doi: 10.1016/0002-9394(64)92500-0. PMID: 14139296.
corticosteroid regimen administered for various ocular and
systemic diseases should be emphasized. 12. Davies TG. Tonographic survey of the close relatives of
patients with chronic simple glaucoma. Br J Ophthalmol. 1968
Conclusion Jan;52(1):32-9. doi: 10.1136/bjo.52.1.32. PMID: 5635901; PMCID:
PMC506519.
Steroid-induced glaucoma is a preventable iatrogenic disease.
The rampant and irrational use of steroids by local medical 13. Podos SM, Becker B, Morton WR. High myopia and primary
practitioners, unmonitored use by patients themselves with open-angle glaucoma. Am J Ophthalmol. 1966 Dec;62(6):1038-
over-the-counter steroids adds to the burden of the disease. 43. PMID: 5957877.
It is important to identify those patients with risk factors
14. Spaeth GL. Traumatic hyphema, angle recession, dexamethasone
hypertension, and glaucoma. Arch Ophthalmol. 1967
Dec;78(6):714-21. doi: 10.1001/archopht.1967.00980030716005.
PMID: 6064921.
15. Francois J. Tissue culture of ocular fibroblast. Ann Ophthalmol
1975 Dec;7(12):1551-1554.
16. Francois J. The importance of the mucopolysaccharides in
intraocular pressure regulation. Invest Ophthalmol. 1975
Mar;14(3):173-6. PMID: 123231.
17. François F, Victoria-Troncoso V. Mukopolysaccharide und
Pathogenese kortisonbedingter Augendrucksteigerung
[Mucopolysaccharides and pathogenesis of cortisone glaucoma
(author's transl)]. Klin Monbl Augenheilkd. 1974 Jul;165(1):5-10.
German. PMID: 4277884.
18. Johnson DH, Bradley JM, Acott TS. The effect of dexamethasone
on glycosaminoglycans of human trabecular meshwork in
perfusion organ culture. Invest Ophthalmol Vis Sci. 1990
Dec;31(12):2568-71. PMID: 2125032.
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DJO Vol. 32, No. 3, January-March 2022
19. Steely HT, Browder SL, Julian MB, Miggans ST, Wilson KL, Clark Cite This Article as: Ashwini Kulkarni, Shweta Tripathi,
AF. The effects of dexamethasone on fibronectin expression in Jatinder Singh Bhalla, Kanika Jain, Shalini Mohan. Steroid
cultured human trabecular meshwork cells. Invest Ophthalmol induced Glaucoma: Dilemma Decoded. Delhi J Ophthalmol
Vis Sci. 1992 Jun;33(7):2242-50. PMID: 1607235. 2022; 32 (3): 15 - 19.
20. Bill A. Editorial: The drainage of aqueous humor. Invest Acknowledgments: Nil.
Ophthalmol. 1975 Jan;14(1):1-3. PMID: 1110131.
Conflict of interest: None declared
21. Wordinger RJ, Clark AF. Effects of glucocorticoids on the
trabecular meshwork: towards a better understanding of Source of Funding: None
glaucoma. Prog Retin Eye Res. 1999 Sep;18(5):629-67. doi:
10.1016/s1350-9462(98)00035-4. PMID: 10438153. Date of Submission: 26 Feb 2022
Date of Acceptance: 21 Mar 2022
22. Zhang X, Clark AF, Yorio T. FK506-binding protein 51 regulates
nuclear transport of the glucocorticoid receptor beta and Address for correspondence
glucocorticoid responsiveness. Invest Ophthalmol Vis Sci. 2008 Jatinder Singh Bhalla
Mar;49(3):1037-47. doi: 10.1167/iovs.07-1279. PMID: 18326728;
PMCID: PMC2442563. MBBS,MS,DNB,MNAMS
23. Shepard AR, Jacobson N, Fingert JH, Stone EM, Sheffield VC, Consultant Head of Glaucoma
Clark AF. Delayed secondary glucocorticoid responsiveness of Services and Incharge Academics,
MYOC in human trabecular meshwork cells. Invest Ophthalmol Deen Dayal Upadhyay Hospital
Vis Sci. 2001 Dec;42(13):3173-81. PMID: 11726619 Hospital New Delhi, India.
E-mail: [email protected]
23. Shokoohi-Rad S, Daneshvar R, Jafarian-Shahri M, Rajaee P.
Comparison between Betamethasone, Fluorometholone and
Loteprednol Etabonate on intraocular pressure in patients
after keratorefractive surgery. J Curr Ophthalmol. 2017 Dec
7;30(2):130-135. doi: 10.1016/j.joco.2017.11.008. PMID: 29988925;
PMCID: PMC6033780.
24. Roth DB, Verma V, Realini T, Prenner JL, Feuer WJ, Fechtner RD.
Long-term incidence and timing of intraocular hypertension after
intravitreal triamcinolone acetonide injection. Ophthalmology.
2009 Mar;116(3):455-60. doi: 10.1016/j.ophtha.2008.10.002. Epub
2009 Jan 20. PMID: 19157561.
25. Espildora J, Vicuna P, Diaz E. Glaucome cortisonique. A propos
de 44 yeux [Cortisone-induced glaucoma: a report on 44 affected
eyes (author's transl)]. J Fr Ophtalmol. 1981;4(6-7):503-8. French.
PMID: 7299067
26. Galin MA, Hirschman H, Gould H, Hofmann I. Does laser
trabeculoplasty prevent steroid glaucoma? Ophthalmic Surg
Lasers. 2000 Mar-Apr;31(2):107-10. PMID: 10743920.
27. Feroze KB, Khazaeni L. Steroid Induced Glaucoma. 2021 Jul
17. In: StatPearls [Internet]. Treasure Island (FL): StatPearls
Publishing; 2021 Jan–. PMID: 28613653.
28. Kersey, J., Broadway, D. Corticosteroid-induced glaucoma:
a review of the literature. Eye 20, 407–416 (2006). https://doi.
org/10.1038/sj.eye.6701895
29. Roberti G, Oddone F, Agnifili L, Katsanos A, Michelessi M,
Mastropasqua L, Quaranta L, Riva I, Tanga L, Manni G. Steroid-
induced glaucoma: Epidemiology, pathophysiology, and clinical
management. Surv ophthalmol. 2020 Jul 1;65(4):458-72. https://
doi.org/10.1016/j.survophthal.2020.01.002
30. Ang M, Ti SE, Loh R, et al. Steroid-induced ocular hypertension
in Asian children with severe vernal keratoconjunctivitis. Clin
Ophthalmol. 2012;6:1253–1258. PMID: 22927736
E-ISSN: 2454-2784 P-ISSN: 0972-0200 19 Quick Response Code
Delhi Journal of Ophthalmology
DJO Vol. 32, No. 3, January-March 2022
Review Article
Multimodality Imaging in Mechanical Orbital Trauma
Ebinesh A, Alpana Manchanda, Radhika Batra, Apoorva Sehgal
Department Of Radiodiagnosis, Maulana Azad Medical College and associated hospitals, New Delhi India.
Orbital trauma is commonly associated with trauma to head and face and the radiologist plays a key role in assessing these
injuries. Common forms of orbital injury include bony fractures, anterior chamber injuries, injuries to lens, open-globe injuries,
ocular detachments, intra-orbital foreign bodies, carotico-cavernous fistula and optic nerve injuries with orbital fractures
being the commonest. Radiographic examination has low sensitivity for soft tissue injuries and is rarely performed. Ultrasound
(USG) can be used to evaluate intraocular injuries and foreign bodies, however has poor sensitivity for evaluating the bone
and retrobulbar area. It is contraindicated in open globe injuries. Computed tomography (CT) is the modality of choice for
Abstract initial imaging in orbital trauma owing to its easy availability, high sensitivity for detection of orbital fractures, and improved
sensitivity for evaluation of soft tissue injury and entrapment. Magnetic resonance imaging (MRI) may be difficult to perform
in an emergency setting, has limited role in evaluating bony injuries and is contraindicated in cases of suspected intra-orbital
metallic foreign body. However, owing to its higher soft tissue contrast resolution, it is indicated in optic nerve injuries, ocular
detachments, carotico-cavernous fistula and particularly when contrast cannot be administered due to deranged renal function.
This article provides a comprehensive account of the role of various imaging modalities in the evaluation of trauma to the orbit
and ocular globe with their imaging features and clinical relevance.
Delhi J Ophthalmol 2022; 32; 20-28; Doi http://dx.doi.org/10.7869/djo.736
Keywords: Orbital Trauma, Imaging, Computed Tomography, Blow Out Fracture, Open Globe Injury, Intraocular Foreign Body
Introduction patients with severe trauma to the head with anterior cranial
vault fracture, a low-dose protocol for orbital imaging should
In the recent era of liberal expansion of automobile usage, be performed to look for orbital trauma which would help
motor vehicle accidents and industrial injuries remain the the radiologist make an accurate diagnosis while limiting
common causes of orbital trauma. In fact, eyes are one of radiation exposure to the lens.
the most protected organs in the body, encased within the
bony orbit. Yet, they are not spared from injury. The World Plain radiographs generally aid in the detection of orbital
Health Organization estimates that trauma to the eye results fractures and radio-opaque intra-orbital foreign bodies.
in blindness in about 1.6 million people and unilateral However, they have a high degree of false negatives in
blindness or decreased vision in 19 million people annually.1 detecting fractures. Ultrasonography (USG) being a non-
In North India, 82.3% of the ocular trauma is associated with invasive, bed side tool can be used for evaluation of ocular
non-occupational causes with sports related injury and road globe injury particularly in the presence of opaque media but
traffic accidents accounting for 23.9% and 23.6% of the cases is insensitive to fractures and carries a risk of acute ocular
respectively.2 Among patients with head injury, 84% have decompensation when performed on patients with globe
associated orbital injury.3 rupture. Magnetic resonance imaging (MRI) has superior
soft tissue resolution but is not recommended in an acute
General Principles Of Imaging In Orbital Trauma setting and is contraindicated in patients with suspicion of
metallic foreign body. The indications for use of various
Role of imaging in mechanical orbital trauma is crucial in imaging modalities are listed in (Table 1).
the diagnosis, evaluation of the extent, classification and in
planning management strategies. Computed tomography Birmingham Eye Trauma Terminology System
(CT) is the imaging modality of choice for evaluation of
orbital trauma. Birmingham Eye Trauma Terminology (BETT) system4 is
a standardized system of terminology used to define and
In the setting of acute trauma, CT imaging has the following classify orbital trauma.
advantages:
● Wide availability The classification is depicted in Figure 1.
● Shorter imaging time and with the advent of helical According to BETT system, the term Eye wall refers only to
the external two layers, sclera and cornea.
multidetector CT, imaging time has further reduced to
a few seconds with enhanced image resolution Closed globe injury: This is an intraocular injury without
● Multiplanar reconstruction full thickness involvement of the eye wall. It is of two types-
● High sensitivity for detection of orbital fractures
● Improved sensitivity for soft tissue injury and A) Contusion: This is usually consequent to blunt trauma
entrapment and can result in impact at the site of injury (eg.
Choroidal rupture) or change in the shape of one globe
Generally in all trauma centers, non-contrast CT imaging (eg. Angle recession).
is routinely done for patients with head injury and orbital
imaging sequences can be acquired in the same sitting if and B) Lamellar laceration: Partial thickness involvement of
when indicated. Most patients with severe head injury have the eye wall usually following sharp trauma.
altered sensorium and lack the ability to convey any ocular
or visual complaints. Hence, it is recommended that in
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DJO Vol. 32, No. 3, January-March 2022
Table 1: Indications for various imaging modalities
Radiograph USG CT MRI
• Suspected case of • Traumatic hyphema • Traumatic hyphema • Suspected trauma to
orbital floor or roof • Traumatic cataract • Traumatic cataract optic nerve to rule out
fracture (if facilty for • Suspected trauma to the • Suspected trauma to the transection/ avulsion
CT imaging is out of
reach) lens for detection of lens lens for detection of lens • Traumatic optic
subluxation, dislocation or subluxation, dislocation or neuropathy
• Detection of capsular rupture capsular rupture
radioopaque • Trauma involving angle of • Trauma involving angle of • Ocular detachment
intraocular foreign anterior chamber to rule out anterior chamber to rule out • Intraocular organic
bodies iridodialysis/ cyclodialysis iridodialysis/ cyclodialysis
• Vitreous hemorrhage • Vitreous hemorrhage foreign body
• Ocular detachment • Ocular detachment (Choroid/ • Detection of
(Choroid/ retina) retina)
• Retinal tears • Retinal tears subperiosteal
hematoma
Open globe injury: This is associated with full thickness iii) Perforating injury: Through and through involvement
involvement of the eye wall. It is also of two types- is seen with perforating injury. Two lacerations (entry
and exit wounds) caused by the same agent are seen
A) Rupture: Full thickness eye wall injury following blunt involving the entire thickness of the eye wall.
trauma causing brief increase in intraocular pressure.
Injury is produced by an inside-out mechanism and the Orbital Fractures
eye wall gives way at its weakest point.
Orbital fractures are usually associated with facial or cranial
B) Laceration: Full thickness eye wall injury produced by vault fractures. Isolated orbital fractures are uncommon.
an outside-in injury mechanism following sharp object Most orbital fractures are undisplaced and do not require
trauma, seen at the site of impact. any surgical intervention. Surgical intervention is required
if there is displacement of fracture fragment with associated
i) Penetrating injury: Single laceration involving full extraocular muscle entrapment or in cases where there
thickness of the eye wall i.e no exit wound. If there are is intraorbital hypertension and vision loss secondary
multiple, each must have been as a result of different to intraorbital hematoma compressing the optic nerve.
impacts. Evidence of potential damage to the globe or optic nerve
impingement indicate surgical emergency and should be
ii) Intraocular foreign body: Penetrating laceration with conveyed to the Ophthalmologist at the earliest.
retained foreign body inside the globe. It is classified
separately due to difference in clinical implication. A) Medial wall fractures
These are usually seen as a posterior extension of naso-
Figure 1: Classification of orbital trauma based on Birmingham Eye Trauma orbito-ethmoid fractures or as a component of Le Fort II/ III
Terminology (BETT) system complex. Medial orbital wall is the thinnest of the bones in
the body and is more susceptible to injury. Lamina papyracea
(posteromedial wall of orbit) shows a convex lateral contour
and bulges into the orbit. This posteromedial bulge is lost
in case of medial orbital wall fracture (Figure 2). Medial
orbital wall fractures can be associated with medial rectus
entrapment. Focal discontinuity of medial wall can often
be missed, but loss of convex contour, presence of ethmoid
hemosinus and intraorbital emphysema should raise a
suspicion of medial wall fracture. Associated entrapment
of the medial rectus muscle should be always ruled out.
Clinically, patients present with pseudo- Duane retraction
syndrome characterized by diplopia, restricted axial ocular
movements and enophthalmos. 5,6
Associated involvement of the lacrimal bone and frontal
process of the maxilla (known as inferomedial orbital sturt)
should be looked for. Lacrimal fossa and frontal process
of maxilla provide a site of attachment for medial canthal
tendons. Fracture involving the medial canthus is usually
associated with disruption of the medial canthal tendons
which require medial canthoplasty. If medial canthal
anatomy is not restored, patients develop telecanthus and
globe malposition.5
Injury to the nasofrontal duct if not attended to, can
predispose to mucocele formation.7
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DJO Vol. 32, No. 3, January-March 2022
Figure 2: Fracture of medial orbital wall Figure 3: Blow out fracture of orbital floor
Axial non- contrast bone window CT image in a 21 year old with history of Coronal reformated non-contrast CT bone window image in a 35 year
road traffic accident shows fracture of the right medial orbital wall (blue old female who sustained a road traffic accident shows blow out fracture
arrow), ethmoid hemosinus and intraorbital emphysema due to extravasation of the floor of left orbit (blue arrow) associated outward displacement of
the inferior rectus and periorbita into the maxillary sinus. The normal
of air from the adjacent ethmoid air cells elliptical contour of the inferior rectus seen on the contralateral side is lost
B) Orbital floor fractures D) Lateral wall and apex fractures
Floor of the orbit akin to the medial wall is thin and fractures Lateral wall and apex fractures are usually associated with
involving the floor are frequent. Entrapment of the inferior complex zygomaticomaxillary fractures (Figure 6). Degree
rectus and resultant restriction of vertical ocular movement of displacement, presence of intraorbital displacement of
and diplopia are usual associations. Inferior orbital wall fracture fragment and its relationship with the optic nerve
should be evaluated in coronal and sagittal reformats. The should be described. Orbital apex fractures can be associated
shape and position of inferior rectus should be carefully with intracanalicular optic nerve compression with resultant
evaluated (Figure 3). A rounded contour with inferiorly sudden loss of vision which might need surgical correction.5
displaced inferior rectus indicates involvement of the
fascial sling5 and might require surgical reconstruction. Figure 4: Fracture of the inferior orbital fissure
If the inferior wall defect is large, there can be associated Axial bone window image in a 17 year old male who presented with
enophthalmos due to herniation of periorbital soft tissue and complaints of epistaxis and numbness over the left cheek with history
inferior rectus into the maxillary sinus along its roof.8 of fall two days back shows fracture of the left inferior orbital fissure
with inwardly displaced fracture fragment (blue arrow). Blow in
Due care should be given while evaluating inferior wall fracture of the lateral wall of left orbit (yellow arrow) is also seen.
fractures in the pediatric population owing to the ‘trapdoor’
phenomenon. Inferior orbital wall in children is pliable Blow-Up, Blow-In And Blow-Out Fractures
so that the fractured bone can spring back and result in a
normal radiological appearance except for inferior rectus Orbital fractures can be classified based on the direction of
and periorbita entrapment.5,7 The radiologist has to carefully fracture as blow-up, blow-in and blow-out fractures.
observe for such injuries because these injuries if not Blow-up fractures involve the orbital roof, sparing the orbital
corrected within 24-72 hours might lead to permanent ocular rim. Fractured bone fragments are displaced superiorly
motility impairment.9 into the cranial fossa. Associated dural tear or intracranial
hemorrhage can be present.
Involvement of infraorbital canal (Figure 4) results in Blow-in fractures involve the orbital floor with intraorbital
sensory loss over the cheek, ala of nose and upper lip due displacement of fracture fragments and might require
to infraorbital nerve injury which might require surgical
attention.6,10
C) Orbital roof fractures
Isolated orbital roof fractures are uncommon and are
usually seen as an extension of anterior cranial vault
fracture (Figure 5). Surgical repair is not indicated unless
there is gross displacement. Presence of associated
pneumocephalus, intracranial hemorrhage, CSF leak and
dural tear that require neurosurgical attention should
be ruled out.7 Direct impact over the superior orbital
rim can result in isolated fracture of the orbital roof
with caudal displacement and resultant exophthalmos.5
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DJO Vol. 32, No. 3, January-March 2022
Figure 5: Fracture of roof of orbit
Axial soft tissue (A) and bone window (B) and coronal reformatted soft tissue (C) and bone window (D) images in a 40 year old female following motor vehicle
accident show fracture of the roof of right orbit (blue arrow) and inracranial intraaxial pneumocephalus (yellow arrow). Few tiny foci of intraparenchymal
hemorrhage are also seen in the vicinity.
surgical decompression if associated with intraorbital
hematoma causing enophthalmos.
Blow-out fractures are associated with outward displacement
of fracture fragments and usually involve the floor and rarely
involve the roof. Blow-out fracture of the floor is associated
with inferior rectus entrapment. Muscle entrapment can often
be overlooked or maybe less conspicuous in the presence of
fat stranding or hematoma. Hence, the radiological findings
should be correlated with a bedside forced duction test.11
Any fracture involving the orbital floor with an area of more
than one sq.cm or more than 50% of the surface area is an
indication for surgical repair.12,13
Anterior Chamber Injury
The portion of the globe between the cornea and the lens is
called anterior chamber. Anterior chamber injuries usually
present with hyphema. USG is not advocated in patients
presenting with hyphema as there can be associated open
globe injury.14 CT can demonstrate blood-fluid level with
dependent hyperattenuating contents within the anterior
chamber. Possibility of associated corneal laceration has to
be ruled out. CT imaging can show iris prolapse and shallow
anterior chamber compared to the normal side.15 Reduced
anterior chamber volume can also be seen in case of anterior
lens subluxation. So, the position of lens should be evaluated
before considering the possibility of corneal laceration.
Injury To Ocular Lens
Lens is a biconvex structure that is suspended from the ciliary Figure 6: Blow in fracture of lateral wall and orbital roof of right orbit
CT orbit axial (A) and coronal reformatted (B) bone window images in a 42
bodies by radially oriented zonular fibres. In blunt ocular year old male with history of fall from height show fracture of the lateral
wall of the right orbit (blue arrow). There is also fracture of the zygomatic
trauma, the wave of impact causes transient deformation process of the right temporal bone (yellow arrow) and fracture of roof of
and equatorial expansion of the globe, displacing the cornea right orbit (orange arrow).
and anterior sclera posteriorly. This results in stretching of
zonular fibres with resultant partial or complete disruption.
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DJO Vol. 32, No. 3, January-March 2022
In partial zonular disruption or tear, there is tear of fibres of three layers- sclera, choroid and retina. Trauma involving
along one margin of the lens while fibres along the other the posterior segment can result in vitreous hemorrhage
half are intact. As a result, there is dependent displacement or disruption of the above mentioned layers with resultant
of the torn portion of the lens, projecting into the vitreous. detachment of the same.
In case of complete zonular disruption, there is tear of the
zonular fibres throughout the lenticular margins with total A) Vitreous hemorrhage
lens displacement. Usually, complete tear is associated Disruption of the retinal vessels following trauma leads
with posterior lens dislocation where the lens can be seen to hemorrhage into the vitreous which is avascular in
lying in the dependent portion of the posterior segment on itself. Acute vitreal hemorrhage appears heterogeneously
imaging because the iris impedes anterior subluxation of hyperechoic on USG. On CT, it is seen as hyperattenuating
lens. Sometimes, in patients with conditions like Marfan’s contents within the posterior segment.
syndrome, Ehler-Danlos syndrome, lens dislocation can be
an incidental finding that is not associated with trauma. B) Retinal detachment
Lens dislocation can be diagnosed on ophthalmoscopy and Retina is the neurosensory layer of the eye and is the
on imaging. innermost layer. Anteriorly it is firmly attached to the
underlying choroid at ora serrata and posteriorly along the
Disruption of the lens capsule can result in lenticular edema margins of the optic disc. In between these attachments, retina
and calcification that eventually result in cataract formation. is loosely attached to the underlying choroid. Traumatic
In the initial stages, affected lens appears hypoattenuating tear of the retina will result in seepage of fluid through
compared to the normal lens and appears hyperattenuating this defect into the potential space between the retina and
or calcified on maturation.16 choroid causing retinal detachment. On USG, CT and MRI,
it has a characteristic ‘V configuration’ with its apex towards
Posterior Segment Injury the disc (Figure 7) and the detached membrane exhibits free
movement on real-time imaging with ultrasound.17
Portion of the globe posterior to the lens is called posterior
segment which is filled with vitreous humor and a wall made
Figure 7: Traumatic retinal detachment with subretinal hemorrhage
Axial B mode ultrasonographic images (A and B) and axial T1W (C), T2W (D) and susceptibility weighted (E) MR images in male child of 12 months who was
brought by his mother with complaints of repeated rubbing of the eyes following a blunt trauma to the left eye a week ago. Ultrasonographic images show the
characteristic ‘V configuration’ of retinal detachment which appears thickened (B) (blue arrow) limited anterolaterally by ora serrata and posteriorly by the optic
disc (yellow arrow head) with anechoic collection within the subretinal space with internal echoes, suggestive of subretinal hemorrhage. The same was confirmed
on MRI which also shows typical ‘V configuration’ of retinal detachment with subretinal hemorrhage appearing hyperintense on T1W (C), hypointense on T2W
(D) showing magnetic susceptibility (E), suggestive of early suacute hemorrhage
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DJO Vol. 32, No. 3, January-March 2022
C) Choroidal detachment necessary due to associated complications such as infection,
Choroid is the vascular middle coat of the globe. Space retinal toxicity, abscess formation and vision loss. CT is the
between the choroid and sclera is called suprachoroidal imaging modality of choice.19, 22-24 Radiographs can detect
space. Following any form of ocular trauma, if there is a fall in the presence of radioopaque foreign bodies. USG can also be
intraocular pressure such as in case of globe rupture, it results useful in detection of intraocular foreign body but has low
in ocular hypotony. Ocular hypotony is associated with fall sensitivity than CT and intraocular air foci can be mistaken
in the suprachoroidal pressure that results in transudation for foreign body.14 MR imaging has a higher sensitivity
of fluid into the suprachoroidal space eventually causing in detection of organic foreign body but the possibility of
choroidal detachment. Tear of choroidal vessels can cause metallic foreign body has to be absolutely excluded prior to
hemorrhagic choroid detachment. On imaging, it has a performing an MR examination.25
biconvex or lentiform configuration extending from the Imaging findings depend on the type of foreign body which
ciliary bodies anteriorly upto the level of the vortex veins are most commonly metal and glass (Figure 9).26 Metallic
posteriorly, sparing the posterior most part.18 In contrast to and glass foreign bodies do not elicit immune response.25
detached retina, detached choroid remains fixed during eye Metallic foreign bodies, even those less than 1 mm in size are
movements on USG. readily detected on CT (Figure 10).15 Detection of intraorbital
glass on CT depends on the type of glass, its attenuation in
Open Globe Injury Hounsfield units (HU) and its size as demonstrated by Gor
MD et al23 in their experiment on porcine eye. They found
Open globe injury can occur following blunt trauma that CT to be the most sensitive modality. Sensitivity of CT was
results in globe rupture due to inside-out mechanism of 96.2% for glass fragments of size 1.5mm and 48.3% for those
impact where sclera gives away at its weakest point, i.e of size 0.5mm. Green beer bottle glass (550 HU) had the
just posterior to the attachment of extraocular muscles.19 It highest detection rate of 90.3% while spectacle glass (80 HU)
can also occur in penetrating or perforating injuries. USG had the least detection rate of 48.3% .23
is contraindicated in patients with suspected open globe
injury. CT is the preferred first line imaging modality. It has Figure 8: Open globe injury with ocular hemorrhage
a sensitivity of 71 to 75% in diagnosing open globe injuries CT orbit axial soft tissue (A) and bone (B) window images in a 52 year old
in patients with strong clinical suspicion. 20,21 However, the male following high impact motor vehicle accident shows altered contour of
sensitivity for diagnosis of occult open globe injury varies the left ocular globe with a focus of air within the globe (yellow arrow head),
from 56 to 68% depending on the observer proficiency.21 MRI representing open globe injury. Left globe appears hyperdense with indistinct
is indicated in patients with clinical suspicion of open globe anterior and posterior segments due to extensive ocular hemorrhage with
injury that are not picked up on CT.17 preseptal soft tissue thickening (blue arrow) and resultant proptosis. Note is
Ocular globe should be evaluated in all planes to rule made of dehiscent medial wall of left orbit (orange arrow)
out open globe injury. There can be direct and indirect
evidences of open globe injury. It becomes obvious in the
presence of extensive trauma such as gunshot or penetrating
or perforating injuries. Direct signs include altered globe
contour, obvious eye wall discontinuity (depicted better on
MRI) and ‘flat tire’ sign. ‘Flat tire’ sign occurs due to loss
of intraocular volume which results in deformed contour of
the globe. Presence of an open globe injury in the posterior
segment will cause extravasation of the vitreous through
the defect that causes sinking of the lens into the posterior
segment and therefore, the anterior chamber appears deeper
than the normal eye. In the presence of anterior chamber
open globe injury as in corneal laceration, the anterior
chamber appears shallow. Presence of an intraocular foreign
body and ocular emphysema should raise a suspicion of
open globe injury (Figure 8).
Non traumatic causes of altered globe contour like coloboma,
staphyloma, pathological myopia should be excluded.11,15
Scleral bands used in treatment of retinal detachment,
silicone oil, scleral buckle, silicon sponge etc can be potential
mimics of intraocular air or foreign body. History of recent
interventions like pneumatic retinopexy, endothelial
keratoplasty, intraocular tamponade should be elicited to
rule out other causes of ocular emphysema.11,15,17
Intraocular Foreign Body
Foreign bodies can be seen in almost 10 to 17% of ocular
injuries.22 Prompt diagnosis of intraocular foreign body is
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DJO Vol. 32, No. 3, January-March 2022
Detection of organic foreign bodies is radiologically cavernous fistula which is characterised by fistulous
challenging but carries high clinical implication as communication between the cavernous segment of internal
they can elicit marked inflammatory response and are carotid artery (ICA) and the cavernous sinus. It occurs due
associated with high infection rates.27 Wood is the most
commonly seen organic foreign body (Figure 11).25 On Figure 10: IIntraorbital metallic foreign body
CT, wood is hypoattenuating and mimics intraocular air Axial bone window image in a 42 year old male welder who presented with
when imaged immediately following injury.17 This can be history of retained metal fragment within the right eye shows the presence
differentiated from air foci due to the presence of geometric of a radiodense metallic foreign body in the extraconal compartment of right
margins.19 It appears isoattenuating in subacute stage and
hyperattenuating in chronic stage with surrounding soft orbit (blue arrow) with associated star artifact.
tissue reaction due to granulomatous inflammation.28 MRI is
the problem solving imaging modality. Appearance of wood
on MRI depends on the type of wood whether it is dry wood
or fresh wood. It appears hypo-to isointense on T1W images
and iso-to hyperintense on T2W images, depending on the
amount of hydration. Dry wood on the other hand has high
air content within and appears hypointense to fat on both
T1W and T2W images.11 T2W and post contrast T1W fat
saturated images are helpful in demonstrating the foreign
body with surrounding enhancing inflammatory response 17
Indications for surgical exploration include copper and lead
foreign bodies, large iron foreign body lodged adjacent to
the sclera, neurological deficit, restriction of ocular mobility
and acute or chronic infection.11 Foreign bodies lodged
in proximity to the apex are preferrably left undisturbed
considering the risk of associated collateral damage.29
Caroticocavernous Fistula
Posttraumatic diplopia, pulsatile proptosis and chemosis a
few weeks following trauma suggest a diagnosis of carotico-
Figure 9:Intraorbital foreign body Figure 11:Intraorbital organic foreign body
CECT face and orbit axial soft tissue (A) and bone window (B), coronal and Axial (A and B) and coronal reformatted (C and D) contrast enhanced CT
sagittal reformatted soft tissue window (C and D) in a 34 year old male who image of a 18 year old male patient who presented with gradually progressive
presented with a history of retained foreign body following assault show swelling in the left eye following penetrating tree branch injury 1 year back
the presence of a long cylindrical foreign body (yellow arrow) seen along show the presence of a well defined hypodense foreign body (yellow arrow)
the inferolateral aspect of the right orbit in the extraconal compartment in the superomedial compartment of left orbit with associated extensive soft
extending upto the right infratemporal fossa. The presence of the foreign tissue reaction (orange arrow) suggestive of granulomatous reaction, which
body is more conspicuous in the soft tissue window than in the bone window is causing mild outward and downward displacement of the left ocular globe.
Coronal T2W TSE FS image (E) of the same patient shows a hypointense
foreign body (yellow arrow) surrounded by heterogenously enhancing soft
tissue reaction (orange arrow) well depicted on coronal post contrast T1 FS
image (F).
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DJO Vol. 32, No. 3, January-March 2022
Figure 12 : Complex facio-orbital fractures Figure 13 : Complex zygomatico-maxillary fracture with orbital fractures
Axial CT (A, C and D) and coronal (B) reformatted bone window images in Axial CT soft tissue window (A) and coronal reformatted bone window (B, C and
a 25 year old female following high intensity road traffic accident show D) in an 18 year old male who presented with history of road traffic accident
fractures of the inferior and lateral orbital walls bilaterally with marked show fractures involving the medial (orange arrow), lateral (yellow arrow)
inferolateral displacement (blue arrow), herniation of orbital contents into and inferior (blue arrow) walls of left orbit. There is comminuted fracture of
the infratemporal and pterygomaxillary fossae (orange arrow) and bone the left lateral orital wall (yellow arrow) with a medially displaced fragment
defect along the inferomedial aspect of the right orbit with herniation of indenting the globe along its superolateral aspect (green arrow) causing a
orbital contents medially into the nasal cavity. There is associated disruption focal contusion on the surface of the globe (blue arrow head). Images also
show comminuted blowout fracture of the left inferior orbital wall (blue
of the right nasolacrimal duct ( blue arrow head) arrow). The left inferior rectus (white arrow head) appears bulky with loss of
normal elliptical contour suggestive of entrapment. Disruption of the lateral
to a tear in the arterial wall of cavernous ICA with fistula and inferior walls with resultant inferolateral dislocation is associated with the
formation that results in reversal of flow in the venous depression and outward displacement of the left globe (yellow arrow head)
tributaries. Therefore, superior ophthalmic vein appears
dilated on CT.15 However, isolated dilatation of superior pressure. Few studies have reported irreversible loss of
ophthalmic vein without demonstration of the fistula can vision within 60-100 minutes of high intraorbital pressure.33
be seen as a normal variant, in cavernous sinus thrombosis, Intraorbital hypertension exceeding the arterial pressure can
venous varix and Grave’s disease. CT Angiography is the cause compromise of the vasa vasorum of the optic nerve
initial investigation for evaluation. However, invasive and central retinal artery resulting in optic nerve and retinal
catheter angiography remains the modality for definitive ischemia respectively. Lack of lymphatic drainage of the orbit
diagnosis and management.30 worsens it further because venous drainage via major veins
like the superior ophthalmic vein are also compromised.11
Traumatic Optic Neuropathy Diagnosis of orbital compartment syndrome is based on
clinical examination characterised by positive apparent
Traumatic optic neuropathy is a cause of post traumatic pupillary defect, fall in visual acuity, tense orbit and rise
vision loss. Role of imaging in traumatic optic neuropathy is in intraocular pressure which necessiates immediate
to evaluate the cause for the same. It can occur due to fracture decompressive canthotomy.11 Role of imaging is to identify
of the optic canal, complete or partial transection of the optic the cause of intraorbital hypertension like intraorbital
nerve or compromised vascularity of the optic nerve. High retrobulbar hemorrhage, extensive emphysema,
resolution CT imaging of the orbital apex is indicated to subperiosteal hematoma or foreign body. On CT imaging,
look for bony injuries at the apex impinging the optic nerve intraocular hypertension is evident by proptosis, stretching
and to guide surgical intervention as these require surgical of optic nerve and conical tenting of the posterior globe
decompression.15 Complete or partial optic nerve transection known as the ‘Guitar pick sign’ defined as a posterior globe
might not necessitate any emergency intervention.11 Patients angle of less than 130°11, 34 Posterior globe angle of 120-130°
with posttraumatic vision loss with radiologically intact have been shown to have good recovery while angle less
optic nerve are treated with high doses of corticosteriods. than 120° indicates poor prognosis with need for emergency
CT might also reveal optic nerve swelling in some of these surgical intervention.34
cases. MRI can depict high T2W signal in the injured optic
nerve. Diffusion weighted (DWI) and diffusion tensor (DTI) Conclusion
imaging have been found to be useful for early diagnosis
of postraumatic optic neuropathy. Apparent diffusion Imaging plays a vital role in the evaluation, classification
coefficient (ADC) and fractional anisotropy (FA) have been and planning management in patients with orbital trauma.
demonstrated to predict the posttraumatic visual acuity in
these patients.31
Orbital Compartment Syndrome
Normal intraorbital pressure is 3 to 6 mm Hg.32 In trauma,
the intraorbital pressure can exceed even the arterial
E-ISSN: 2454-2784 P-ISSN: 0972-0200 27 Delhi Journal of Ophthalmology
DJO Vol. 32, No. 3, January-March 2022
CT is the most preferred imaging modality. Orbital trauma 24. Patel SN, Langer PD, Zarbin MA, et al. Diagnostic value of
is usually associated with facial and/ or head trauma. clinical examination and radiograpic imaging in identification
Therefore, clinical examination cannot always be relied of intraocular foreign bodies in open globe injury. Eur J
upon. Often, the radiologist is the first to diagnose orbital Ophthalmol 2012; 22: 259-68.
and ocular injury. Appropriate and timely imaging helps
in early diagnosis and prompt management of orbital and 25. Fulcher TP, McNAb AA, Sullivan TJ. Clinical features and
ocular injuries thereby improving outcomes and prevent management of intraocular foreign bodies.. Ophthalmology
permanent visual disability. 2002; 109: 494-500.
References 26. Nasr AM, Haik BG, Fleming JC, et al. Penetrating orbital injury
with organic foreign bodies. Ophthalmology 1999; 106: 523-32.
1. Pradhan E, Sundar G, Mahat P, et al. Imaging in ocular and
ocular adnexal trauma. Eyewiki. American Academy of 27. John SS, Rehman TA, John D, et al. Missed diagnosis of a
Ophthalmology 2021 ID : 9326. wooden intraorbital foreign body. Indian J Ophthalmol 2008;
56: 322-24.
2. Maurya RP, Srivastav T, Singh VP, et al. The epidemiology of
ocular trauma in Northern India: A teaching hospital study. 28. Martel BMP, Adenis JP, Rulfi JY, et al. CT appearance of
Oman J Ophthalmol 2019; 12: 78-83. chronically retained wooden intraorbital foreign bodies.
Neuroradiol 2001; 43: 165-8.
3. Kulkarni AR, Aggarwarl SP, Kulkarni RR, et al. Ocular
manifestations of head injury: A clinical study. Eye 2005; 19: 29. Ho VH, Wilson MW, Fleming JC, et al. Retained intraorbital
1257-63. metallic foreign bodies. Ophthal Plast Reconstr Surg 2009; 20:
232-6.
4. Kuhn F, Morris R, Witherspoon DC. Birmingham eye trauma
terminology (BETT): terminology and classification of 30. Anderson K, Collie DA, Capewell A. CT angiographic
mechanical injuries. Ophthalmo Clin North Am 2002; 15: 13943. appearances of carotico-cavernous fistula. Clin Radiol 2001; 56:
514-16.
5. Caranci F, Cicala D, Cappabianca S, et al. Orbital fractures: Role
of imaging. Semin Ultrasound CT MR 2012; 33: 385-91. 31. Yang QT, Fan YP, Zou Y, et al. Evaluation of traumatic optic
neuropathy in patients with optic canal fracture using diffusion
6. Hopper RA, Salemy S, Sze RW. Diagnosis of midface fractures tensor magnetic resonance imaging: a preliminary report. ORL
with CT: What the surgeon needs to know. Radiographics 2006; J Otorhinolaryngol Relat Spec 2011; 73: 301-7.
26: 783-93.
32. Kratky V, Hurwitz JJ, Avram DR. Orbital compartment
7. Joseph JM, Glavas IP. Orbital fractures: A review. Clin syndrome. Direct measurement of orbital tissue pressure. Can
Ophthalmol 2011; 12: 95-100. J Ophthalmol 1990; 25: 293-7.
8. Kontio R, Lindqvisr C. Management of orbital fractures. Oral 33. Hayreh SS, Kolder WE, Weingeist TA. Central retinal artey
Maxillofac Surg Clin North Am 2009; 21: 209-20. occlusion and retinal tolerance time. Ophthalmology 1980; 87:
75-8.
9. Grant JH 3rd, Patrinley JR, Weiss AH, et al. Trapdoor fracture
of the orbit in a pediatric population. Plast Reconstr Surg 2002; 34. Dalley RW, Robertson WD, Rootman J. Globe tenting: a sign of
109: 482-89. increased orbital tension. AJNR 1989; 10: 181-6.
10. Lee YS, Kim HS, Hwang JH,e t al. Sensory recovery after Cite This Article as: Ebinesh A, Alpana Manchanda,
infraorbital nerve avulsion injury. Arch Craniofac Surg 2020; 21: Radhika Batra, Apoorva Sehgal Multimodality Imaging in
244-48. Mechanical Orbital Trauma Delhi J Ophthalmol 2022; 32 (3):
20 - 28.
11. Lin KY, Ngai P, Echogoyen CJ, et al. Imaging in orbital trauma.
Saudi J Ophthal 2012; 26: 427-32. Acknowledgments: Nil.
12. Cole P, Boyd V, Banerji S, et al. Comprehensive management of Conflict of interest: None declared
orbital fractures. Plast Reconstr Surg 2007; 120: 57S-63S.
Source of Funding: None
13. Rinna C, Ungari C, Saltarel A. Orbital floor restoration. J
Craniofac Surg 2005; 16: 968-72. Date of Submission: 12 Nov 2021
Date of Acceptance: 16 Jan 2022
14. Feilding JA. The assessment of ocular injury by ultrasound. Clin
Radiol 2004; 59: 301-12. Address for correspondence
Ebinesh A, Resident
15. Kabul SW. Imaging of orbital trauma. Radiographics. 2008; 28:
1729-39. Department Of Radiodiagnosis, Maulana
Azad Medical College and associated
16. Bron AJ, Vrensen GF, Koretz J, et al. The aging lens. hospitals, New Delhi India.
Ophthalmologica 2000; 214: 86-104. E-mail: [email protected]
17. Sung EK, Nadgir RN, Fujita A, et al. Injuries of the globe: What Quick Response Code
can the radiologist offer? Radiographics 2014; 34: 764-76.
18. Dalma-Weiszhausz J, Dalma A. The uvea in ocular trauma.
Ophthalmol Clin North Am 2002; 15: 205-13.
19. Dunkin JM, Crum AV, Swanger RS, et al. Globe Trauma. Semin
Ultrasound CT MR 2011; 32: 51-6.
20. Joseph DP, Pieramici DJ, Beauchamp NJ. Computed tomography
in the diagnosis of open globe injuries. Ophthalmology 2000;
107: 1899-1906.
21. Arey ML, Mootha VV, Whittemore AR, et al. Computed
tomography in the diagnosis of occult open globe injuries.
Ophthalmology 2007; 114: 1448-52.
22. Pinto A, Brunese L, Daniele S, et al. Role of computed
tomography in the assessment of intraorbital foreign bodies.
Semin Ultrasound CT MR 2012; 33: 392-95.
23. Gor DM, Krisch CF, Leen J et al. Radiological differentiation of
intraocular glass: evaluation of imaging techniques, glass type,
size, and effect of intraocular hemorrhage. AJR Am J Roentgenol
2001; 177: 1199-1203.
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DJO Vol. 32, No. 3, January-March 2022
Original Article
High Diagnostic And Therapeutic Value of Digital Subtraction
Angiography in Direct Carotid-Cavernous Fistulas:
A Retrospective Case Series
Vijaya Sahu1, C.D.Sahu2, Nidhi Pandey3, Bhagyashri Bhutada4
1Department Of Ophthalmology, AIIMS Raipur, Chhattisgarh, India.
2,4Department of Radiology Pt. J. N. M. Medical College Raipur, Chhattisgarh, India.
3Department of Ophthalmology, Pt. J. N. M. Medical College Raipur, Chhattisgarh, India.
Aims: To describe the diagnostic and therapeutic value of digital subtraction angiography (DSA) and endovascular treatment in
patients with direct carotid cavernous fistula (CCF) over a period of three years.
Settings: Tertiary referral hospital, Chhattisgarh
Design: Retrospective, noncomparative case series.
Material & Methods: Medical records of consecutive patients who had direct CCF between January 2014 to January 2017 with
minimum six months of follow-up were retrospectively analyzed. All patients were initially evaluated by non-invasive imaging
technique followed by DSA for confirmation. Endovascular embolization was done in all cases. A clinical cure was considered
Abstract when there was a complete resolution of signs and symptoms of direct CCF and when the fistula was not observed on repeat
DSA after three months, which was labeled as anatomically cured patients.
Results: Total ten patients were analyzed; nine patients had unilateral CCF, only one had bilateral CCF. All patients had history
of head trauma. Five (50%) patients were embolized with a coil, and the rest were embolized by a combination of coil and Onyx.
In our study, carotid artery preservation was performed in 70% of patients. Latest clinical follow up showed good recovery
Furthermore no procedure related complications were noted in any patients. There were no intraoperative or perioperative
mortality noted.
Conclusion: With the observed results and low rate of complications and morbidity, endovascular therapy could be the primary
treatment for patients with direct CCFs.
Delhi J Ophthalmol 2022; 32; 29-34; Doi http://dx.doi.org/10.7869/djo.737
Keywords: Digital subtraction angiography, direct carotid cavernous fistulas, Endovascular embolization
Introduction diagnosis and treatment of direct CCFs because untreated
direct CCFs always results in poor visual prognosis, but can
Management of neuro-ophthalmic disorders has been be managed promptly.
dramatically revolutionalized by the advancements in
neuroimaging and interventional techniques.1 Digital Subjects and Methods
subtraction angiography (DSA) is an interventional
technique. The study was approved by the institutional ethical
committee and adhered to the tenets of the Declaration of
First developed in the 1970s and it is useful in the Helsinki. Informed consent was obtained from all patients
diagnosis and treatment of arterial and venous occlusions, before initiation of DSA and endovascular procedure. This
arteriovenous malformations, and carotid-cavernous fistulas was a retrospective observational study of patients with
(CCFs).2 direct CCF visiting our department between January 2014
to January 2017. Case records of all ten patients with direct
CCF is defined as an abnormal communication between the CCF during the study period who underwent angiographic
cavernous sinus and the carotid artery branches, which is evaluation and endovascular procedure were drawn from
categorized into direct and indirect types by Barrow. Type A a medical record department. Data from patients more
(direct) fistulas involve a direct communication between the than eighteen years age with features of direct CCF and
intracavernous portion of the internal carotid artery (ICA) with a minimum follow up to six months were included
and cavernous sinus, commonly due to trauma.3 Direct for analysis. Patients with any prior ocular conditions
CCFs are typically high flow type and usually requires active that may influence visual acuity such as corneal opacity,
intervention because spontaneous resolution is rare.4 The glaucoma or retinal pathology were excluded from study.
traditional management of CCFs is associated with mortality A retrospective analysis of all noninvasive imaging studies
and several complications.5 With advanced catheterization and angiographic reports was performed. The records were
techniques and new embolizing agents, endovascular reviewed for demographic variables like age and sex, mode
treatment is considered the treatment of choice for all CCFs. of trauma, time interval between injury and admission
DSA determines the angioarchitecture of the injury and and comprehensive ophthalmic evaluation including
provides precise information about the size, location, and best corrected visual acuity (BCVA) using Snellen’s
character of the fistula and its drainage pattern.6,7 chart, intraocular pressure assessment using applanation
This study aimed to evaluate the efficacy of DSA for the tonometry, dilated fundus examination using slit lamp
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DJO Vol. 32, No. 3, January-March 2022
biomicroscopy and indirect ophthalmoscope. BCVA was copolymer, dimethyl sulfoxide, and tantalum powder. It
categorized into three categories- mild visual impairment comes in two separate vials that are mixed 20 min prior to
(6/9 to 6/12), moderate visual impairment (6/18 to 6/36) and injection. It forms a cast after coming in contact with the
severe visual impairment (less than 6/60). ionic material. It is better than glue because it has better
control over the injection. Its only disadvantage is its higher
All patients were independently evaluated by an cost compared to other agents.9
ophthalmologist and a radiologist before and after the
treatment. A retrospective analysis of all non-invasive Results
imaging studies and angiographic reports were done. All
patients were first evaluated using noninvasive imaging Data from ten patients that satisfied the inclusion criteria
techniques, followed by DSA for definitive diagnosis and were analyzed. The mean age of patients was 34.3yrs with
management. Follow-up was scheduled at one, three, and six range from 24-55 years and eight (80%) were males. There
months of treatment. A clinical cure was considered when were five right sided CCFs, four left side CCFs and one
there was a complete resolution of signs and symptoms of bilateral CCF. All the patients of direct CCFs were preceded
direct CCFs, which was labeled as clinically cured patients, by head trauma. Seven of them had motor vehicle accident,
and when the fistula was not observed on repeat DSA after two had accidental fall and one had sports injury. The time
three months, which was labeled as anatomically cured interval from injury to admission ranged from 20 days to
patients. The primary outcome measure was resolution six weeks (mean, 25.3 days). On ocular examination we
of signs and symptoms of direct CCF after endovascular found that seven patients had severe visual impairment,
treatment and secondary outcome measure was change two patients had moderate visual impairment and only one
in BCVA after treatment. The one-line improvement in patient was presented with mild visual impairment.
Snellen’s chart after procedure is considered as fair visual
recovery, two-line improvement as good visual recovery Ocular findings were evaluated- ten (100%) patients
and more than three-line improvement as a very good visual demonstrated the signs of chemosis and subconjunctival
recovery. hemorrhage, eight (80%) presented with lid edema, and six
(60%) had proptosis with bruit, raised intra ocular pressure
Procedure of digital subtraction angiography and diplopia in five (50%) patients. The visual acuity was
recorded with Snellen’s chart- 4 patients had mild visual
Written informed consent was obtained from all patients impairment, 5 patients had moderate visual impairment and
after undergoing pre-anesthetic checkup. The standard only one patient presented with severe visual impairment.
transfemoral Seldinger technique was used in all patients. (Table 1)
After the selective injection of the ICA, ECA, and vertebral
artery bilaterally, standard anteroposterior and lateral Table 1: Tabulation of ocular finding details
radiography and three-dimensional rotational angiography
were performed. This provided precise information Ocular Features No of Patients presented
about the location of the fistula, collateral supply to the with ocular finding
brain, and venous drainage pattern of the lesion. After subconjunctival Hemorrhage 10
complete assessment of the anatomy and architecture of chemosis
CCFs, embolization treatment strategies were planned 8
accordingly. Small carotid artery tears were treated with Lid edema 6
closure alone, while in cases with larger fistula trapping of Pulsatile Proptosis with bruit 5
the ICA, embolization using a coil or liquid embolus (Onyx) 5
was considered. Hemostasis was achieved at the end of the Increase IOP 2
procedure.8 In the present study, we used coil and a liquid Diplopia 6
embolizing agent (i.e., Onyx).
Disc edema
Coils: They are made up of platinum or steel and hence Dilatation of retinal vessels only
easily visible on radiographic films. They induce clotting
owing to the Dacron wool tails around the wire. They are Visual Acuity 4
significantly good for fast-flowing vessels because they Mild Visual Impairment 5
immediately clot the vessel. Coils are better than balloon Moderate Visual Impaiment 1
embolization because of the ease of access and availability Severe visual Impairment
of embolic devices of various sizes.7 However, coils have a
disadvantage in that a risk of incomplete fistula occlusion On fundus examinations, disc edema was noted only in
with loss of transarterial access is observed when using coils. two (20%) patients and slight dilatation of retinal vessels
Thus, some complications, such as thromboembolism, ICA in six (60%) patients Imaging evaluation of direct CCF
compromise by protruding coils, and ICA dissection, can be by contrast-enhanced computed tomography (CT) and
observed.4 magnetic resonance angiography revealed a dilated superior
ophthalmic vein in all patients. After noninvasive imaging,
Liquid Embolic Agent (Onyx): It is a liquid embolic diagnostic DSA was performed in all cases, and endovascular
agent formed by a combination of ethylene vinyl alcohol embolization therapy was planned accordingly.
Five patients were treated with coil embolization of the
fistula. In two patients, closure of the fistula was performed
without occlusion of the parent artery (Figure 2). The
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DJO Vol. 32, No. 3, January-March 2022
remaining three patients with large tears in the ICA and repeat embolization, which, on further follow-up after
good collateral circulation from the contralateral ICA were three months, showed complete obliteration. All patients
treated with embolization of the fistula with trapping of demonstrated significant improvement in clinical symptoms
the ICA (Figure 1). In the other five patients, embolization with regression of chemosis, proptosis, and decrease or
was performed using a combination of coils and Onyx. absence of bruit within 2–3 days after the procedure (Figure
The patient with a bilateral CCF required two sittings of 4). Five patients showed good visual recovery, four patients
endovascular treatments, one for each side. The right-sided had very good visual recovery and only one had fair visual
fistula closed first, followed by the left side at an interval of recovery after embolization.
one month (Figure 3).
No signs of distal embolization, cerebral hemorrhage, cranial
In repeat DSA at one month, nine out of ten patients showed nerve palsy, or cerebral ischemia were observed in any of
complete closure of the fistulas. One patient required the patients. One of the patients complained of diminished
Figure 1: Lateral DSA, preprocedure internal carotid artery (ICA) angiogram (image A) shows direct fistula (arrow) between cavernous sinus and ICA with
enlarged draining Superior ophthalmic Vein. Post procedure angiogram (image B) after coiling of fistula with trapping of ICA (arrow) shows no flow in fistula
Figure 2: Image A shows Direct CCF (arrow) with dilated superior ophthalmic vein (SOV) and post procedure (post-coiling) image (B) shows complete obliteration
of fistula (arrow) with preservation of internal carotid artery (ICA)
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DJO Vol. 32, No. 3, January-March 2022
Figure 3: Bilateral CCF, (A) coronal view, (B) lateral view, showing obliteration of right-side fistula with coiling, without trapping of internal carotid artery with
left side dilated cavernous sinus
Figure 4: Pre-operative clinical picture (image A) and post-operative picture day 3 (image B)
vision in the affected eye following the procedure but or presence of collagen disorders such as Ehlers-Danlos
recovered spontaneously after 24 hours. None of the patients syndrome type IV.12
reported signs or symptoms of recurrence within six months In the present study, all patients had experienced head
of follow-up. Intraoperative or perioperative mortality was trauma, similar to previous studies.13,14 Cavernous sinus is
not observed. prone to injury owing to its anatomical location, where the
artery is completely surrounded by venous structures, and
Discussion to the close proximity of the ICA to surrounding dura at
skull base. Hence, it is immediately affected by shear force
We found that timely management with endovascular during trauma.15
techniques through DSA was associated with good visual
recovery and resolution of all sign and symptoms of direct Direct CCFs are commonly observed in men, as further
CCF. A direct CCF is a rare life-threatening condition and confirmed by the current study.15
the most common cause of CCFs is trauma (76%).10,11
In present study, all cases of direct CCFs were abrupt in
Other causes can be iatrogenic in origin, such as after onset and progressed rapidly and presented with proptosis,
transsphenoidal surgery for pituitary adenomas, treatment
of trigeminal neuralgia, thrombectomy of the carotid artery,
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DJO Vol. 32, No. 3, January-March 2022
subconjunctival hemorrhage, chemosis, and diminished Conclusion
vision.16,17 Transmission of high-pressure arterial blood
into the cavernous sinus and draining veins led to venous Untreated direct CCF always results in poor visual prognosis,
hypertension, which is responsible for all the four mentioned but can be managed promptly. With the observed results
signs and symptoms.5 and low rate of complications and morbidity, endovascular
therapy could be the primary treatment for patients with
Traumatic CCFs might be overlooked initially because of direct CCFs.
the critical condition of patients. Mild visual impairment is
common in 60%–90% of patients with direct CCFs, but there References
could be progressive loss of vision or even total visual loss in
approximately 25% of patients.12 According to some studies, 1. Kakaria AK. Imaging in neuro-ophthalmology: An overview.
89% of untreated cases could have visual impairment, but if Oman J Ophthalmol. 2009;2(2):57-61.
closed completely, vision could improve in 94% of patients.18
In present study, we also found visual acuity improvement 2. Barrow DL, Spector RH, Braun IF, Landman JA, Tindall SC,
in all ten patients but very good visual improvement was Tindall GT. Classification and treatment of spontaneous carotid-
found in 50% of patients at the end of 1 month. cavernous sinus fistulas. J Neurosurg. 1985;62(2):248-256.
The current study demonstrated that noninvasive modalities 3. Ringer AJ, Salud L, Tomsick TA. Carotid cavernous fistulas:
such as contrast-enhanced CT and magnetic resonance anatomy, classification, and treatment. Neurosurg Clin N Am.
angiography imaging can be considered in diagnosing CCFs, 2005;16(2):279-295.
which typically show tortuous dilated superior ophthalmic
veins (the hockey stick sign),19 which can then be confirmed 4. Ellis JA, Goldstein H, Connolly ES Jr, Meyers PM. Carotid-
using the gold standard DSA.12 cavernous fistulas. Neurosurg Focus. 2012;32(5):E9.
doi:10.3171/2012.2.FOCUS1223.
In the current study, all patients underwent active
intervention, as majority of the subjects presented with 5. Korkmazer B, Kocak B, Tureci E, Islak C, Kocer N, Kizilkilic O.
moderate visual impairment. The first treatment for CCFs Endovascular treatment of carotid cavernous sinus fistula: A
reported in 1809 was ligation of the common carotid artery systematic review. World J Radiol. 2013;5(4):143-155.
and is still preferred in some selected cases.5,20 Currently,
endovascular therapy is considered the treatment of choice 6. Ovitt TW, Newell JD 2nd. Digital subtraction angiography:
for all CCFs. technology, equipment, and techniques. Radiol Clin North Am.
1985;23(2):177-184.
Endovascular treatment of CCFs in the 1970s was performed
with detachable balloons, which were replaced by coils in 7. Gemmete JJ, Ansari SA, Gandhi DM. Endovascular techniques
the 1990s, followed by the era of liquid embolizing agents for treatment of carotid-cavernous fistula. J Neuroophthalmol.
such as Onyx.13,21,22 2009;29(1):62-71.
In the current study, the transarterial approach was chosen 8. Ahn SH, Prince EA, Dubel GJ. Basic neuroangiography: review
for all patients. Five (50%) patients were embolized with a of technique and perioperative patient care. Semin Intervent
coil, and the rest were embolized by a combination of coil Radiol. 2013;30(3):225-233.
and Onyx. In our study, carotid artery preservation was
performed in 70% of patients, whereas it was performed in 9. Arat A, Cekirge S, Saatci I, Ozgen B. Transvenous injection of
81% of patients in another similar study.23 The 100% closure Onyx for casting of the cavernous sinus for the treatment of a
of fistula after treatment noted in this study was similar to carotid-cavernous fistula. Neuroradiology. 2004;46(12):1012-
that reported in other studies.24,25,26 1015.
The current study demonstrated adequate closure of Barrow 10. Biousse V, Mendicino ME, Simon DJ, Newman NJ. The
type A fistula (direct CCF) without any adverse neurological ophthalmology of intracranial vascular abnormalities. Am J
complications, the only limitation being its small sample Ophthalmol. 1998;125(4):527-544.
size.
11. Lewis AI, Tomsick TA, Tew JM Jr. Management of 100 consecutive
Role of Ophthalmologist direct carotid-cavernous fistulas: results of treatment with
detachable balloons. Neurosurgery. 1995;36(2):239-245.
Although all the interventions presented in present
study were performed by interventional radiologists, but 12. Naesens R, Mestdagh C, Breemersch M, Defreyne L. Direct
ophthalmologists definitely have an important role. The carotid-cavernous fistula: a case report and review of the
Ophthalmologists should be able to establish an initial literature. Bull Soc Belge Ophtalmol. 2006;(299):43-54.
presumptive diagnosis, as many patients with CCFs may
initially present to ophthalmologists. They should be 13. Serbinenko FA. Balloon catheterization and occlusion of major
able to order appropriate diagnostic tests and be able to cerebral vessels. J Neurosurg. 1974;41(2):125-145.
monitor patients. Timely referral to a neurosurgeon or
neurointerventional radiologist is the key to successful closure 14. Tjoumakaris SI, Jabbour PM, Rosenwasser RH.
of fistulas and could be performed by ophthalmologists. Neuroendovascular management of carotid cavernous fistulae.
Neurosurg Clin N Am. 2009;20(4):447-452.
15. Fabian TS, Woody JD, Ciraulo DL, et al. Posttraumatic carotid
cavernous fistula: frequency analysis of signs, symptoms, and
disability outcomes after angiographic embolization. J Trauma.
1999;47(2):275-281.
16. Anderson K, Collie DA, Capewell A. CT angiographic
appearances of carotico-cavernous fistula. Clin Radiol.
2001;56(6):514-516.
17. de Keizer R. Carotid-cavernous and orbital arteriovenous
fistulas: ocular features, diagnostic and hemodynamic
considerations in relation to visual impairment and morbidity.
Orbit. 2003;22(2):121-142.
18. Korkmazer B, Kocak B, Tureci E, Islak C, Kocer N, Kizilkilic O.
Endovascular treatment of carotid cavernous sinus fistula: A
systematic review. World J Radiol. 2013;5(4):143-155.
19. Tu YK, Liu HM, Hu SC. Direct surgery of carotid cavernous
fistulae and dural arteriovenous malformations of the cavernous
sinus. Neurosurgery. 1997;41(4):798-806.
20. Chi CT, Nguyen D, Duc VT, Chau HH, Son VT. Direct traumatic
carotid cavernous fistula: angiographic classification and
treatment strategies. Study of 172 cases. Interv Neuroradiol.
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2014;20(4):461-475. Cite This Article as: Vijaya Sahu, C.D.Sahu, Nidhi Pandey,
21. Bhatia KD, Wang L, Parkinson RJ, Wenderoth JD. Successful Bhagyashri Bhutada. High diagnostic and therapeutic value of
“Digitalsubtractionangiography”indirectcarotidcavernousfistulas
treatment of six cases of indirect carotid-cavernous fistula – A Retrospective case series Delhi J Ophthalmol 2022 32 (3) 29-34
with ethylene vinyl alcohol copolymer (Onyx) transvenous Acknowledgments: Nil
embolization. J Neuroophthalmol. 2009;29(1):3-8. Conflict of interest: None declared
22. Teitelbaum GP, Larsen DW, Zelman V, Lysachev AG, Source of Funding: None
Likhterman LB. A tribute to Dr. Fedor A. Serbinenko, founder of Date of Submission 25 Jun 2021
endovascular neurosurgery. Neurosurgery. 2000;46(2):462-470. Date of Acceptance: 26 Jan 2022
23. Pham Minh Thong, Bui Van Giang. Treatment of direct carotid
cavernous fistula under endovascular intervention.Vietnam J Address for correspondence
Practical Med. 2003; 459 (9): 54-56. Vijaya Sahu M.S. Ophthalmology
24. Redekop G, Marotta T, Weill A. Treatment of traumatic
aneurysms and arteriovenous fistulas of the skull base by using Associate professor, Department
endovascular stents. J Neurosurg. 2001;95(3):412-419. of Ophthalmology, AIIMS Raipur,
25. Barr JD, Lemley TJ. Endovascular arterial occlusion accomplished Chhattisgarh, India.
using microcoils deployed with and without proximal Email: [email protected]
flow arrest: results in 19 patients. AJNR Am J Neuroradiol.
1999;20(8):1452-1456..
26. Suzuki S, Lee DW, Jahan R, Duckwiler GR, Viñuela F.
Transvenous treatment of spontaneous dural carotid-cavernous
fistulas using a combination of detachable coils and Onyx. AJNR
Am J Neuroradiol. 2006;27(6):1346-1349.
Quick Response Code
E-ISSN: 2454-2784 P-ISSN: 0972-0200 34 www.djo.org.in
DJO Vol. 32, No. 3, January-March 2022
Original Article
Cross Sectional Study on Awareness About Eye Banking in
Moradabad (India)
Archana Chaudhary, Maitri Paul, Ashi Khurana, Lokesh Chauhan
Department of Ophthalmology C L Gupta Eye Institute, Ram Ganga Vihar, Phase 2 (Ext) Moradabad, India.
Purpose: There has been a shortage of transplantable corneal tissue in developing countries. Assessing awareness about eye
banking would help us in making effective strategies to overcome this.
Methods: A cross-sectional descriptive study was conducted using a standard pretested closed-ended structured questionnaire.
Survey interview was conducted by an independent trained interviewer. Questionnaire had eighteen questions to assess
awareness (6 questions), knowledge (6 questions) and process (6 questions) of eye donation.
Results: A total of 396 individuals of more than 18 years participated in this survey. A total of 269 (67.9%) participants were
Abstract aware that eyes can be donated and 156 (39.4%) participants agreed to donate their eyes after their death. Of all, 251 (63.4%)
were aware that family consent is needed for eye donation and 172 (43.4%) participants thought that one needs to come to
an eye hospital for eye donation. Only 82 (20.7%) participants know an eye bank facility in their nearby area. Of all, 86 (21.7%)
participants believed that eyes can be donated by a living person and 24 (6.1%) believed that they need to pay for eye donation.
Conclusion: Majority of participants know that eyes can be donated. However a low percentage of them agreed to donate their
eyes after death. Awareness was low in terms of knowledge and process of eye banking. To increase awareness, innovative
community based strategies to be implemented in the study area which ultimately increase cornea retrieval.
Delhi J Ophthalmol 2022; 32; 35-39; Doi http://dx.doi.org/10.7869/djo.738
Keywords: Eye Bank, Awareness, Cornea Retrieval, Eye Donation, Knowledge
Introduction community participation. Public awareness about eye
Corneal diseases are among the major causes of vision banking has a potential to increase eye donation which can
loss and avoidable blindness globally. This has been ultimately reduce the backlog of transplantable corneal
of public health concern (both in social and economic tissue. Awareness of eye banking in different population has
terms) in most developing countries. According to rapid been reported by many previous studies.11-15
survey on avoidable blindness conducted under National
Programme for Control of Blindness and Visual Impairment During regular record review, it has been noticed that there
(NPCB&VI) during 2015-18, prevalence of blindness was has been a lot of difference between the number of patients
0.45%.1 Corneal blindness had been the third main cause with corneal opacities who need corneal transplant and the
of blindness, accounted for 0.9% after cataract (62.6%) and rate of donor tissue collection at a tertiary eye care institute
refractive error (19.7%). Various community-based studies in western Uttar Pradesh. In the past, the polio eradication
conducted in India have reported the prevalence of corneal program also faced challenges from this area due to low
blindness.2-7 In developing countries effective strategies education, awareness and personal beliefs of the general
have been implemented for cataract backlog and refractive population.15-18 Looking at this, this community based study
error corrections.8 However comparatively less focus has was conducted to assess the awareness level about eye
been given to programs dealing with other causes of visual banking among the general population residing at western
impairment such as corneal blindness. Uttar Pradesh (India). These results will help us to make
community based strategies which would ultimately reduce
Unlike cataract, corneal blindness also affects people of the transplantable corneal tissue backlog in the study area.
younger age, which results in a very high disability adjusted
life years (DALYs) compared to cataract. A study from south Methodology
India had reported that the average age of patients with The study was approved by CL Gupta Eye Institute Ethics
blindness caused by corneal opacities was significantly lower Committee (ECR/1310/Inst/UP/2019) and conducted in
than blindness caused by cataract.9 Corneal transplantation compliance with the tenets of declaration of Helsinki. A cross
has been the most important sight restoring procedure for sectional survey was conducted among adult participants
corneal blindness. This procedure has high returns since aged more than 18 years. Study area district was divided
this disease has been associated with very high DALYs. into eight blocks. Out of these eight blocks, four blocks were
Underdeveloped eye banking infrastructure has been one randomly selected for survey. Community field workers
of the potential barrier to corneal transplantation. India were trained to conduct study surveys. Participants were
needs approximately needed 277,100 donor tissues and randomly selected from the catchment area of the institute
there has been a shortage of transplantable corneal tissue.10 vision centers located in these blocks. Quality control
Although there are some areas in India with excellent system was implemented during data collection to ensure
Hospital Cornea Retrieval Programs and are able to meet uniformity and accuracy of the data. Identified participants
the demand for corneal tissue, but in smaller towns most were invited to participate in this survey. The objective of
eye donations are still voluntary mostly depending on the study was discussed with study participants and they
E-ISSN: 2454-2784 P-ISSN: 0972-0200 35 Delhi Journal of Ophthalmology
DJO Vol. 32, No. 3, January-March 2022
were requested to sign the inform consent. Participants Figure 1: Eye banking awareness distribution among literate and illiterates
who gave their consent were enrolled in the survey. The
participants were asked to answer each question face-to-face Figure 2: Eye banking awareness distribution among male and female
with one trained interviewer (field worker). Each interview
took approximately 20-25 minutes and was conducted at Of all, 251 (63.4%; 95% CI: 58.4-68.1%)) were aware that
places which were comfortable to all participants. After family consent is needed for eye donation and only 81
the interview, general information about eye banking was (20.5%; 95% CI: 16.6-24.8%) participants agreed to donate
provided by the interviewer. Pretested content validated eyes of their close ones after their death. A total of 172
questionnaire was developed with the help of experienced (43.4%; 95% CI: 38.5-48.5%) participants thought that one
faculty and literature search. Questionnaire consists of needed to come to an eye hospital for eye donation. Only
demographic information, and questions to assess awareness 34 (8.6%; 95% CI: 6-11.8%) participants knew anyone who
about eye banking. Questionnaire had eighteen questions had donated his/her eyes and 30 (7.6%; 95% CI: 5.2-10.6%)
to assess awareness (6 questions), knowledge (6 questions) participants knew someone who had undergone corneal
and process (6 questions) of eye donation. Questionnaire transplantation (received donated corneal tissue). A total of
was pretested on staff working at the institute to assess its 82 (20.7%; 95% CI: 16.8-25%) participants know an eye bank
internal consistency. However the data generated during facility in their nearby area. Of all, 86 (21.7%; 95% CI: 17.8-
pretesting was not included in the final analysis. 26.1%) participants believed that eyes can be donated by
a living person and 214 (54%; 95% CI: 49-59%) know that
Statistical Analysis donated eyes can be transplanted by an ophthalmologist.
Of all participants, 42 (10.6%; 95% CI: 7.8-14.1%) believed
All analysis were performed using Statistical software IBM that whole globe, 121 (30.6%; 95% CI: 26.1-35.4%) believed
SPSS Statistics version 20. Descriptive statistics were obtained cornea and 5 (1.3%; 95% CI: 0.4-2.9%) sclera has been
to determine the frequency and proportions. Mean and recovered during eye donation. Regarding time duration for
standard deviation was calculated for continuous variables. tissue recovery, 111 (28%; 95% CI: 23.7-32.7%) participants
Summaries of descriptive statistics and group comparisons responded that the duration was within 6 hours, 25 (6.3%;
are provided, which were made using the unpaired t-test for 95% CI: 4.1-9.2%) up to 10 hours, and 260 (65.6%; 95% CI:
continuous data and the chi square test for proportions. 60.7-70.3%) participants were not aware of any timeline.
A total of 35 (8.8%) participants responded that donated
Sample size calculation: Based on awareness percentage, eyes can be preserved till 3 days, 26 (6.6%; 95% CI: 6.2-
p=50% i.e. 0.5, q=1-p, α=0.05, allowable error, d=5% and 12.1%) participants till 7 days, 15 (3.8%; 95% CI: 2.1-6.2%)
applying formula Zα2pq/d2, sample size for this survey was participants till 14 days. When asked who performed the
384. Assuming data losses due to incomplete questionnaires, recovery, 320 (80.8%; 95% CI: 76.6-84.6%) participants said it
the sample size was adjusted to 400. was the doctor, 17 (4.3%; 95% CI: 2.5-6.8%) said optometrist
and 40 (10.1%; 95% CI: 7.3-13.5%) said eye bank technician.
Results Of all, 72 (18.2%; 95% CI: 14.5-22.3%) believed that the older
A total of 396 individuals of more than 18 years participated
in this survey. The mean age of participants was 36.1±13.6
(Range: 18-82) years. Of all participants 235 (59.3%) were
male and 161 (40.7%) were female (p=0.00; one sample
binomial test). Education level and occupation of study
participants are presented in (Table 1). A total of 269 (67.9%;
95% CI: 63.1-72.5%) participants were aware that eyes can
be donated and 156 (39.4%; 95% CI: 34.6-44.4%) participants
agreed to donate their eyes after their death. Among literates,
199 (76.9%) participants were aware of eye donation as
compared with 70 (51.1%) among illiterates (p=0.00, Fisher’s
exact test) (Figure 1). Among males, 176 (74.8%) participants
were aware of eye donation as compared with 93 (57.7%)
among females (p=0.002, Fisher’s exact test) (Figure 2).
Table 1: Frequency Distribution of Occupation and Education of Study
Participants
Occupation Frequency Percent
Business 139 35.1
Service 108 27.3
149 37.6
Not working
Education 259 65.4
Literate 137 34.5
Illiterate 396 100.0
Total
E-ISSN: 2454-2784 P-ISSN: 0972-0200 36 www.djo.org.in
DJO Vol. 32, No. 3, January-March 2022
age group may require more than one cornea transplantation Regarding awareness about eye donation, a majority of
surgery. A total of 170 (42.9%; 95% CI: 38-48%) participants the population surveyed were aware of eye donation. This
had not known the process to become an eye donor. Of all, was related to the education level of study participants. A
24 (6.1%; 95% CI: 3.9-8.9%) participants had the incorrect significantly more number of participants were literate and
information that one needs to pay for eye donation and 151 among them significantly higher numbers were aware of eye
(38.1%; 95% CI: 33.3-43.1%) participants responded that they donation as compared to illiterate participants. Also the male
were not aware of this. Only 39 (9.8%; 95% CI: 7.1-13.2%) participants were significantly more aware compared to
participants know the correct eye bank information service female participants. This relates to the education level since
toll free number. Frequency distribution of responses are among the study population; significantly more number of
presented in Table 2. male participants (73.6% male versus 53.4% female) were
Table 2: Frequency distribution of Occupation and Education of study participants
S.No Questions Yes No Don't Know
Q1 Can Eye Be Donated 269(67.9%) 69 (17.4%) 58 (14.6%)
Q2 Are you opt for eye donation after your 156 (39.4%) 161 (40.6%) 79 (19.9%)
death
Q3 Do you donate eye of your closed one 81 (20.4%) 156 (39.4%) 159 (40.2%)
after their death
Q4 Do you know anyone who has donated 34 (8.5%) 362 (91.5%) NA
eyes
Q5 Do you know anyone who has received 30 (7.5%) 366 (92.5%) NA
donated eye
Q6 Eyes can be donated by a living person 86 (21.7%) 224 (56.5%) 86 (21.7%)
Q7 Donated eyes can be transplanted 214 (54.1%) 83 (20.9%) 99 (25%)
Q8 Which part of eye will be donated Whole Globe Cornea Sclera Don’t Know
42 (10.6%) 121 (30.5%) 5 (1.2%) 228 (57.5%)
Q9 Time duration for eye donation Within 6 Hrs. Up to 10 Hrs. Don’t Know
42 (10.6%) 121 (30.5%) 233 (58.8%)
Q10 How many days donated eyes can be 3 Days 7 Days 14 Days Don’t Know
preserved 35 (8.8%) 26 (6.5%) 15 (3.7%) 320 (80.8%)
Q11 Who takes the eyes Ophthalmologist Physician Optometrist Eye Bank Technician Don’t Know
136 (34.3%) 27 (6.8%) 17 (4.2%) 40 (10.1%) 176 (44.2%)
Q12 Which age group can need re- Old Age Group Young Age Don’t Know
transplantation Group
72 (18.2%) 130 (32.8%) 194 (48.9%)
Q13 Is family consent is required for eye 251 (63.4%) 90 (22.7%) 55 (13.8%)
donation
Q14 Do you need to come to an eye hospital 172 (43.4%) 132 (33.3%) 92 (23.2%)
for donating eyes of deceased
Q15 Do you know your nearby eye bank 82 (20.7%) 314 (79.3%) NA
Q16 Do you know the process of becoming 139 (35.1%) 257 (64.9%) NA
an eye donor 24 (6.1%) 221 (55.8%) 151 (38.1%)
Q17 Do you have to pay for eye donation
Q18 Do you know Eye banking toll free 39 (9.8%) 357 (90.1%) NA
number
Discussion literate. This also points out the need to educate the large
illiterate population by alternative means of publicity than
Significantly more male participants were included in this printed materials .This corroborates with the results of
study. Probably because when field workers visited the survey conducted by Acharya et al, where 88.45% of study
family, the male of that family being the decision maker population heard about eye donation.19 They also reported no
in most cases in rural India, preferred to answer the correlation between eye donation and its prior knowledge.19
questionnaire. Preponderance of male participants has also Although they have not relate this finding to the education
been reported in a recent survey on awareness about eye level of their study participants. Higher education level in
banking by Acharya et al and Lal et al.19,20 the developed countries had been found related to consent
E-ISSN: 2454-2784 P-ISSN: 0972-0200 37 Delhi Journal of Ophthalmology
DJO Vol. 32, No. 3, January-March 2022
of families for eye donation of their deceased relatives.12 of information about eye banking was through healthcare
The awareness level of our study is higher to the previously facilities and relatives followed by mass media, brochures
reported studies.11,21-23 This can be explained by the large scale and social gathering.19 Lal et al reported significantly higher
publicity by a highly active volunteer group supporting the percentage of medical and nursing students had received
eye bank in the study area. information through media campaigns as compared to
information received from hospital itself.20 Door to door
Although a high awareness level has been reported in the education by field workers or through ASHA workers can
study still only 40% of the study population agreed for eye be another strategy to deal with these barriers.
donation after their death and further only 20% of them
agreed to donate eyes of their close relatives. This was due In conclusion, simple publicity by print media is not effective
to their personal or religious beliefs about eye donation. This in creating correct awareness about eye donation in rural
reflects that only awareness of an individual is not enough and semi urban India unless more innovative strategies
for eye donation, their personal beliefs prevail over their involving religious leaders and community health workers
awareness level while making a decision on eye donation. are developed to reach out to the illiterate population.
Innovative community based strategies must be adopted
to overcome this barrier to eye donation in the study References
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the World: Available from https://www.pciglobal.org/visible- Cite This Article as: Archana Chaudhary, Maitri Paul, Ashi
progress-in-the-fight-against-polio-in-moradabad-and-the- Khurana, Lokesh Chauhan. Cross sectional study on awareness
world/ about eye banking in Moradabad (India) Delhi J Ophthalmol
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joco.2018.02.002 Department of Public Health Research,
21. Krishnaiah S, Kovai V, Nutheti R, Shamanna BR, Thomas R, Rao C L Gupta Eye Institute, Ram Ganga
GN. Awareness of eye donation in the rural population of India. Vihar, Phase 2 (Ext) Moradabad, India
Indian J Ophthalmol. 2004;52:73–8. E-mail: [email protected]
22. Priyadarshini B, Srinivasan M, Padmavathi A, Selvam S,
Saradha R, Nirmalan PK. Awareness of eye donation in an
adult population of Southern India. A pilot study. Indian J
Ophthalmol. 2003;51:101–4.
23. Lawlor M, Kerridge I. Anything but the eyes: Culture, identity,
and the selective refusal of corneal donation. Transplantation.
2011;92:1188.
E-ISSN: 2454-2784 P-ISSN: 0972-0200 39 Quick Response Code
Delhi Journal of Ophthalmology
DJO Vol. 32, No. 3, January-March 2022
Original Article
Retrobulbar Amphotericin B in Mucormycosis: A Ray of Hope
Shalini Mohan1, Kunal Sahai2, Namrata Patel1, Tejasvini Chandra1, Priyesh Kumar1
1Department of Ophthalmology, GSVM Medical College, Kanpur, India.
2Department of Medicine, GSVM Medical College, Kanpur, India.
Aim: The aim of the study was to study the role of Retrobulbar Amphotericin B in patients with Mucormycosis.
Methods: The retrospective study conducted on 86 cases at a tertiary care hospital analyzed detailed history, examination and
management options. The staging was done on basis of clinical and radiological examination. Management included functional
endoscopic sinus debridement followed by lavage with Liposomal Amphotericin B. The patients with ocular involvement were
subjected to Exenteration or Retrobulbar injections of Amphotericin B (3.5 mg / ml) based on the disease staging.
Abstract Results: Most common risk factors were steroid intake (89.5 %) and Diabetes (87.2%). Seventy four eyes of 71 patients had ocular
involvement out of which 20 eyes (27.0%) of 19 patients (26.7%) presented with no perception of light. Seven patients were subject
to exenteration of globe and 58 eyes were given Retrobulbar injections (Mean number of injections = 5.58 ± 2.36).The mean best
corrected visual acuity of 0.769± 0.935 logMar did not deteriorate (p=0.871) post treatment. The mean restriction of extraocular
movements were 2.32± 1.09 which improved to 1.56 ± 1.56 (p=0.0031) following retrobulbar injections.
Conclusion: The patients of Mucormycosis without cerebral involvement can be subjected to Retrobulbar Amphotericin B injections
that can control the ocular manifestations and stabilise the vision thus saving the globe..
Delhi J Ophthalmol 2022;32; 40-44; Doi http://dx.doi.org/10.7869/djo.739
Keywords: Amphotericin B, Covid, Exenteration, Mucormycosis, Retrobulbar Injection
Introduction Material & Methods
The pandemic of Covid infection affected majority of The study participants were 86 cases of biopsy confirmed
population in its second wave. The trailing end of the Mucormycosis admitted at a tertiary care hospital in North
pandemic lead to another epidemic; Mucormycosis in India. The participants were subjected to written & informed
developing nations like India.1,2 It’s an angioinvasive disease consent for all the procedures performed. All procedures
caused by saprophytic fungi of the order Mucorales whose performed were in accordance with the ethical standards
main pathogenic feature is tissue infarction and necrosis.1-3 of the institutional and/or national research committee and
with the 1964 Helsinki Declaration and its later amendments
The exact incidence is unknown due to lack of population or comparable ethical standards.
based studies but the estimated prevalence in India is 70
times higher in comparison to developed nations which Study design: It was a retrospective study done on the
were estimated to be at 0.02 to 9.5 cases (with a median of 0.2 patients admitted in dedicated ward for Mucormycosis after
cases) per 100,000 persons.3,4 Annual incidence reported is the confirmed biopsy report.
of 12.9 cases per year during 1990–1999,5 35.6 cases per year
during 2000–2004 6cases per year during 2000–2004 6 1999,5 Detailed history and examination was recorded from the bed
35.6 cases per year during 2000–2004,6 and 50 cases per year head tickets (BHT) for all the patients done by dedicated team
during 2006–2007.7 The overall numbers increased from 25 of doctors that included Otorhinologists, Ophthalmologists,
cases per year (1990–2007) to 89 cases per year (2013–2015).8 Physicians, Radiologists & Neurologists. All the findings
were noted from the BHTs of the patients and entered in an
Rhino-Orbito-Cerebral-Mucormycosis (ROCM) is the excel spread sheet by a dedicated person. The diagnosis was
most common form reported from India in contrast to confirmed by KOH mount of nasal swab and tissue biopsy
developed nations where most common form is pulmonary taken from the effected turbinate of the patients that was
mucormycosis.1-4 The tissue infarction and necrosis of sent to microbiology lab of the institution.
retro-orbital space and subsequent Orbital Apex Syndrome
lead to various ophthalmic manifestations including total Blood investigations that included complete blood count
ophthalmoplegia, proptosis, loss of vision etc.1,2,8 (CBC), inflammatory markers, renal function tests, liver
function tests and serum electrolytes were analyzed at
The most common causes reported in previous studies admission, two weeks and 4 weeks after admission. (Contrast
have been Diabetes Mellitus, haematological malignancy enhanced MRI was done for all patients with regards to
and chemotherapy, haematopoietic stem cells, and solid- involvement of paranasal sinuses (PNS), orbit and brain
organ transplant recipients on immunosuppressive therapy, done at the time of admission and 3 weeks after admission).
patients on long-term steroid, patients with iron overload,
patients on peritoneal dialysis, extensive skin injury/burn, The patients were subjected to endoscopic sinus debridement
human immunodeficiency virus (HIV) infection, and followed by injection of liposomal Amphotericin B lavage by
voriconazole therapy.1,2,8 Otorhinologists after confirmation of diagnosis. Immediately
after confirmation of diagnosis injection liposomal
The main aim of the study was to find out the demography, Amphotericin B (5 mg/kg/day) was initiated for the patients
risk factors and the role of Retrobulbar Amphotericin B with Rhino-Orbito-Mucormycosis (ROM) and dose of 10
(RAMB) in patients with biopsy proven Mucormycosis. mg/kg/day was started in patients with ROCM for infection
of the central nervous system.
E-ISSN: 2454-2784 P-ISSN: 0972-0200 40 www.djo.org.in
DJO Vol. 32, No. 3, January-March 2022
The patients with eye involvement were categorized by (17.4%) were found to have no eye involvement clinically
Staging of ROCM published by Sen M, Honavar SG et al.9 The and radiologically. Three patients out of 71 patients (82.5%)
subjects with ROM without cerebral involvement or without with ocular involvement had bilateral signs. Therefore, 74
risk of cerebral involvement were subjected to Retro-orbital eyes of 71 patients, out of 20 eyes (27.0%) of 19 patients
Amphotericin B (RAMB) injection (3.5 mg/ml in 1 ml). The (26.7%) presented with no perception of light (PL negative).
subjects with 3a and 3b staging were given alternate day Amongst these 20 eyes, three eyes of 2 patients presented
RAMB and stage 3c were given daily injections till 5 doses. with blindness due to Central Retinal Artery Occlusion
The RAMB were repeated on the basis of clinical response (CRAO). Another patient had lost vision due to optic neuritis
and were followed up both clinically and by imaging. and rest of the eyes (16 eyes of 16 patients) presented with
The photographs taken were analyzed to document the orbital apex syndrome.
regression of signs especially ocular movements in 9 gazes, The Mean BCVA of the patients with eye involvement
proptosis, ptosis and Best Corrected Visual Acuity (BCVA.) (excluding patients with PL negative vision) were 0.769 ±
0.935 log Mar units that changed to 0.734 ± 0.928 log MAR
The patients with 3d staging were assessed with regards to units at 3 weeks (p=0.871) post treatment it remained
cerebral involvement by neurologists. These patients with unchanged at 6 weeks post treatment.
ROCM were subjected to exenteration along with lavage Mean intraocular pressure (IOP) was 17.7 ± 8.3 mm Hg in the
of orbital cavity by Amphotericin B injection along with affected 74 eyes of 71 patients at the time of admission and
endoscopic sinus debridement surgery. 14.7 ± 4.35. (p= 0.195) 3 weeks post treatment. Four patients
had raised IOP for which antiglaucoma medication was
Five patients died during due course of treatment who were started. The mean IOP in unaffected eyes of the 68 patients
admitted with cerebral involvement and/or brain abscess. (as 3 patients had bilateral involvement) was 15.35 ± 4.2 mm
Four patients left against medical advice (LAMA) so their Hg. The difference between affected and unaffected eye was
follow up examination could not be included in the data 2.35 ± 4.1 mm Hg (p = 0.303)
analysis. [The involvement of extraocular muscles on clinical
examination was assigned numbers according to the
All the data were entered in Microsoft excel spread sheet restriction of movement of eye. One number was assigned
and the statistical analysis was done by Statplus software for one muscle involvement (movement restriction in
AnalystSoft Inc (version V7, 2021) . The mean and standard one direction) and number 4 was assigned for 4 muscles
deviation were calculated by descriptive statistics. Two tailed involved and 5 was assigned for restriction of movements in
p value (p<0.05) was taken as significant after calculation of all the gazes (total ophthalmoplegia)]. The mean restriction
mean difference from paired ‘t’ test. of ocular movement in the 74 eyes of 71 patients were 2.74
± units 1.37. Complete ptosis was present in 15 (20.2%) and
Results partial ptosis was present in 17 (22.9%) out of 71 patients.
The staging of the disease showed maximum patients in
Total of eighty six post covid patients were admitted and Stage 3b, done as per involvement on contrast enhaced MRI
were found to have biopsy confirmed Mucormycosis report of orbit (Figure 1).9
(Table 1). There were 61 males (70.9%) and rest were females. The mean restriction of ocular movements in the patients
Mean age was 52.164 ± 13.1 years ( Median = 52 years). who were given RAMB (58 eyes) were 2.32units ± 1.09units.
The patients who underwent exenteration (7 in numbers),
Total of 75 patients (87.2%) were having Diabetes Mellitus expired (5 in nos) and LAMA (4 in numbers) were excluded
(mean Hb1Ac = 8.98 ± 2.98) out of which 23 patients to get a total of 58 eyes receiving RAMB. The mean number of
(30.6%) were on insulin. The next common systemic
illness was hypertension in 47(54.6%) patients followed by Figure 1: Staging of ocular manifestations on basis of contrast enhanced MRI
hypercholesterolemia in 23 (26.7%) patients. in patients with Mucormycosis
The history of vaccination revealed that only three patients
(3.4%) were immunised by single dose of Covishield vaccine
(Oxford-AstraZeneca, SII, Pune, India). Rest of the patients
did not take even a single dose of vaccine.
Thirty three patients (38.3%) were hospitalised for the
treatment of Covid, out of which 27 (81.8%) were given
oxygen during their hospital stay. Rest all patients were
treated at home. The mean duration of presentation to
hospital with symptoms of Mucormycosis after Covid
negative report was 9.5 ± 4.98 days (Medium = 10 days,
Range 0 to 20 days)
Seventy patients (89.5%) took steroid medications for their
treatment of Covid infection, out of which 31 patients (43.6%)
were put on injectable steroids.
The mean BCVA of all patients at admission was 0.518 ±
0.881 log MAR units that changed to 0.515 ± 0.857 log MAR
units (p= 0.90) after 3 weeks of treatment. Fifteen patients
E-ISSN: 2454-2784 P-ISSN: 0972-0200 41 Delhi Journal of Ophthalmology
DJO Vol. 32, No. 3, January-March 2022
RAMB injections given were 5.58± 2.36 (range 3 - 15) which The mean age revealed that maximum number of cases
lead to improvement in mean ocular restriction (Figure 2) to were in the age group of 30-45 years (36%) followed by 45
1.56 ± 1.56 from 2.32 ± 1.09 (p=0.0031). – 60 years (33.7%). Males were more than the females which
appear to be by chance due to a small sample size. Most
The complete ptosis improved in 9 out of 15 (60%) patients common systemic associations were reported in Diabetes
(Figure 3) and partial ptosis improved in 13 out of 17 (76.4%) Mellitus and systemic steroid intake as is seen with other
patients (Figure 4). Two patients of 7 exenterated eyes were studies too.1,2,11,12
given 3 RAMB before exenteration but no improvement in
the clinical status lead to the decision for exenteration. All The history of hospitalization for Covid infection was found
Figure 2: Nine gaze ocular movements pre RAMB Injection and post RAMB injection showing decreased periorbital ecchymosis and improved ocular movements
Figure 3: Improvement in complete ptosis after RAMB injections
the patients who underwent exenteration, survived and in only one third of cases so, it can’t be included as a major
were discharged satisfactorily. Patients were discharged on risk factor. The median time of presentation was 9 days
Posaconazole tablet (300 mg twice daily on day one followed (maximum 20 days) after covid negative report emphasizing
by once daily dosing). that second week post covid infection is the most crucial for
presentation of Mucormycosis.
Discussion
The history of vaccination revealed that only 3.4% percent
The upsurge in the cases of Mucormycosis post Covid were vaccinated by single dose of vaccine and rest all were
infection lead to another epidemic in the ongoing not vaccinated. Emphasising the fact that probably the
pandemic.10-11 The panic rose due to high incidence of vaccine provided sufficient immune protection to covid
mortality and morbidity due to loss of eyes/vision and posed survivors so that immunity levels of individuals didn’t
a great challenge in management of these cases.12
E-ISSN: 2454-2784 P-ISSN: 0972-0200 42 www.djo.org.in
DJO Vol. 32, No. 3, January-March 2022
Figure 4: Improvement in partial ptosis, proptosis & conjunctival chemosis post RAMB injections
decline to the levels that post Covid complications like 2. Rao V, Arakeri G, Madikeri G, Shah A, S Oeppen R, A Brennan
secondary infections can affect them.13-15 Although a larger P. Post-COVID Mucormycosis in India: A formidable challenge
sample size with other infections should be considered to [published online ahead of print, 2021 Jun 29]. Br J Oral
say these facts conclusively. Maxillofac Surg. 2021;doi:10.1016/j.bjoms.2021.06.013
The management protocol included debridement 3. Prakash H, Chakrabarti A. Epidemiology of Mucormycosis
by functional endoscopic sinus surgery (FESS) by in India. Microorganisms. 2021 Mar 4;9(3):523. doi: 10.3390/
Otorhinologist, that remained the mainstay in all patients microorganisms9030523. PMID: 33806386; PMCID: PMC8000977
followed by daily Liposomal Amphotericin B injection.11-13
The patients with eye involvement were given RAMB as 4. Prakash H, Chakrabarti A . Global Epidemiology of
per the protocol described in the material and methods.11 Mucormycosis. J Fungi (Basel). 2019 Mar 21;5(1):26. doi: 10.3390/
The RAMB injections have been reported in some sections jof5010026.
sporadic case reports16-18 but this is one of the largest series
of patients receiving RAMB and responding positively to 5. Chakrabarti A, Das A, Sharma A, Panda N, Das S, Gupta KL,
it. The RAMB also proved to be effective in restoring the Sakhuja V. Ten years' experience in zygomycosis at a tertiary
ocular movements (p=0.0031) of the patients (figure 2) and care centre in India. J Infect. 2001 May; 42(4):261-6.
also helped to restore the eyelid movements (figure 3 and 4).
Therefore, the need for exenteration was reduced in majority 6. Chakrabarti A, Das A, Mandal J, Shivaprakash MR, George VK,
of the patients. The patients with lost vision could not Tarai B, Rao P, Panda N, Verma SC, Sakhuja V. The rising trend
regain their visual acuity14 but restoration of eyelids/ocular of invasive zygomycosis in patients with uncontrolled diabetes
movements saved the eye and improved psychology due to mellitus. Med Mycol. 2006 Jun; 44(4):335-42
preserved cosmesis for the patients.
7. Chakrabarti A, Chatterjee SS, Das A, Panda N, Shivaprakash
The conclusion was drawn that post covid patients can MR, Kaur A, Varma SC, Singhi S, Bhansali A, Sakhuja V Invasive
present with deadly secondary infections like mucormycosis. zygomycosis in India: experience in a tertiary care hospital.
The patients who present without cerebral involvement can Postgrad Med J. 2009 Nov; 85(1009):573-81
be subjected to RAMB injections that can control the ocular
manifestations and stabilise the vision of the patient and 8. Prakash H, Ghosh AK, Rudramurthy SM, Singh P, Xess I, Savio
subsequently can save the globe of the patients. Although J, Pamidimukkala U, Jillwin J, Varma S, Das A, Panda NK, Singh
a randomised controlled trial / prospective study on larger S, Bal A, Chakrabarti A. A prospective multicenter study on
number of subjects is requested to provide more conclusive mucormycosis in India: Epidemiology, diagnosis, and treatment.
results. Med Mycol. 2019 Jun 1; 57(4):395-402
References 9. Shah K, Dave V, Bradoo R, Shinde C, Prathibha M. Orbital
Exenteration in Rhino-Orbito-Cerebral Mucormycosis: A
1. Mahalaxmi I, Jayaramayya K, Venkatesan D, et al. Mucormycosis: Prospective Analytical Study with Scoring System. Indian
An opportunistic pathogen during COVID-19 [published J Otolaryngol Head Neck Surg. 2019 Jun;71(2):259-265.
online ahead of print, 2021 Jul 6]. Environ Res. 2021;111643. doi:10.1007/s12070-018-1293-8
doi:10.1016/j.envres.2021.111643
10. Reid G, Lynch JP 3rd, Fishbein MC, Clark NM. Mucormycosis.
Semin Respir Crit Care Med. 2020 Feb; 41(1):99-114
11. Sen M, Honavar SG, Bansal R, Sengupta S, Rao R, Kim U, et
al. Epidemiology, clinical profile, management, and outcome
of COVID‑19‑associated rhino‑orbital‑cerebral mucormycosis
in 2826 patients in India – Collaborative OPAI‑IJO Study on
Mucormycosis in COVID‑19 (COSMIC), Report 1. Indian J
Ophthalmol 2021;69:1670-92
12. Cornely OA, Alastruey-Izquierdo A, Arenz D, et al.
Mucormycosis ECMM MSG Global Guideline Writing Group.
Global guideline for the diagnosis and management of
E-ISSN: 2454-2784 P-ISSN: 0972-0200 43 Delhi Journal of Ophthalmology
DJO Vol. 32, No. 3, January-March 2022
mucormycosis: an initiative of the European Confederation Cite This Article as: Shalini Mohan, Kunal Sahai, Namrata
of Medical Mycology in cooperation with the Mycoses Study Patel, Tejasvini Chandra Priyesh Kumar. Retrobulbar
Group Education and Research Consortium. Lancet Infect Dis. Amphotericin B in Mucormycosis: A Ray of Hope. Delhi
2019 Dec;19(12):e405-e421. doi: 10.1016/S1473-3099(19)30312-3. Journal of Ophthalmology.2022; Vol 32, No (3): 40 - 44.
Epub 2019 Nov 5. PMID: 31699664. Acknowledgments: Nil
13. Skiada A, Lass-Floerl C, Klimko N, Ibrahim A, Roilides Conflict of interest: None
E, Petrikkos G. Challenges in the diagnosis and treatment Source of Funding: None
of mucormycosis. Med Mycol. 2018;56(suppl_1):93-101. Date of Submission: 02 Jan 2022
doi:10.1093/mmy/myx101 Date of Acceptance: 10 Feb 2022
14. Mehta S, Pandey A. Rhino-Orbital Mucormycosis Associated
With COVID-19. Cureus. 2020 Sep 30;12(9):e10726. doi: 10.7759/ Address for correspondence
cureus.10726. PMID: 33145132; PMCID: PMC7599039 Shalini Mohan, MS,DNB, Associate Prof
15. Singh AK, Singh R, Joshi SR, Misra A. Mucormycosis in
COVID-19: A systematic review of cases reported worldwide and Department of Ophthalmology,
in India [published online ahead of print, 2021 May 21]. Diabetes GSVM Medical College, Kanpur,
Metab Syndr. 2021;15(4):102146. doi:10.1016/j.dsx.2021.05.019 UP, India.
16. Hirabayashi, Kristin E. M.D.*; Kalin-Hajdu, Evan M.D.*; Brodie, Email : [email protected]
Frank L. M.D.*; Kersten, Robert C. M.D.*; Russell, Matthew
S. M.D.†; Vagefi, M. Reza M.D.*Retrobulbar Injection of
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Issue 4 - p e94-e97 doi: 10.1097/IOP.0000000000000806
17. Colon-Acevedo B, Kumar J, Richard MJ, Woodward JA. The
Role of Adjunctive Therapies in the Management of Invasive
Sino-Orbital Infection. Ophthalmic Plast Reconstr Surg. 2015
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26207927.
18. Joos ZP, Patel BC. Intraorbital Irrigation of Amphotericin B in
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IOP.0000000000000377. PMID: 25794024.
E-ISSN: 2454-2784 P-ISSN: 0972-0200 44 Quick Response Code
www.djo.org.in
DJO Vol. 32, No. 3, January-March 2022
Original Article
Effects Of Long-Term Use of Topical Antiglaucoma Drugs on
Ocular Surface: A Cross Sectional Study
Aparajita Richhariya1, Anshu Sahai1, Mohammad Abid Shamshad1, Pukhrambam Ratan Kumar1, Maryem Ansari2
1Department of Ophthalmology, Sahai Hospital and Research Centre, Jaipur, Rajasthan, India.
2Department of Pathology, Pandit Deen Dayal Upadhyay Hospital Jaipur, Rajasthan, India.
Purpose: Glaucoma is a chronic progressive disease and a major risk factor for blindness. This study aimed to evaluate the
long-term effects of topical antiglaucoma drugs on ocular surface.
Methods: This was a cross-sectional study, which included patients with glaucoma who had been taking one/two/three
topical drugs (minimum 3 months) and control group of newly diagnosed glaucoma (10 months). The patients were
divided into test groups A1 (timolol 0.5%/ briminodine 0.1%/ bimatoprost 0.01%), A2 (dual combination of any of the
above drugs), A3 (triple combination) and control. Schirmer-I, tear film breakup time (TBUT), rose bengal, conjunctival
impression cytology and ocular surface disease index (OSDI) scores were evaluated.
Abstract Results: A total of 164 patients were enrolled and divided into groups A1, A2, A3 and control, respectively. There was a
significant difference in Schirmer’s test (mm) results between the groups (15.06, 13.77, 11.24 and 21.26 in A1, A2, A3 and
control, respectively; p<0.001). The mean TBUT (seconds) was 9.84, 8.25, 5.29 and 12.33 in A1, A2, A3 in control group,
respectively (p<0.001 timolol 0.5% plus briminodine 0.1% plus bimatoprost 0.01%). Abnormal rose bengal was higher
in A2 and A3 than A1 (3.94, 5.92 and 2.55, respectively; p<0.001). The mean conjunctival impression cytology grades
were more severe in subgroups A1 (1.83), A2 (1.70) and A3 (2.74) than control group (0.96). The mean OSDI scores were
significantly (p<0.001) higher in A2 (34.62) and A3 (49.63) than A1 (25.93).
Conclusion: Topical antiglaucoma drugs caused OSD on long term use. The severity of OSD was higher in multiple drug
combinations in comparison to single drug.
Delhi J Ophthalmol 2022;32; 45-49; Doi http://dx.doi.org/10.7869/djo.740
Keywords: Bimatoprost, Brimonidine, Conjunctival Impression Cytology, Glaucoma, Ocular Surface Disease, Rose Bengal, Schirmer-I.
Introduction of monotherapy vs. dual and triple anti-glaucoma therapies
comprising of timolol, brimonidine and bimatoprost on the
The patients with primary open-angle glaucoma (POAG) ocular surface in POAG, the outcomes of this study would
have a reduced quality-of-life even in milder cases and be an add on data for clinician’s reference as well as to the
during initial stages of the disease that worsen with time.7 The already established evidence.
management include surgical/pharmacological approach
with systemic/topical agents in combination of two/three Materials and Methods
drugs belonging to different classes with the primary
target of lowering intraocular pressure(IOP).10-12 The most This was a cross-sectional study conducted at the Department
commonly used antiglaucoma drugs are prostaglandins of Ophthalmology, Sahai Hospital and Research Centre,
prescribed as once-daily dose (latanoprost, travoprost, Jaipur, Rajasthan from January to October 2019. The study
bimatoprost), β-blockers (timolol), and α-agonist as twice- was approved by Institutional Ethics Committee (NHMECJ/
daily dose (brimonidine). JPR/2019/01). Written informed consent was obtained from
all the study patients before enrolment.
Despite proven efficacy timolol, brimonidine and
bimatoprost, these drugs have ocular and systemic adverse Patients with POAG who had been taking one/two/three
effects.13,14 Prostaglandin analogues are potent and first line topical antiglaucoma drugs for a minimum of 3 months and
IOP lowering drugs used in POAG.15 However, bimatoprost who were newly diagnosed with POAG in past 10 months
is reported to cause conjunctival hyperemia.16-18 Timolol is (with no past history of topical antiglaucoma medications)
reported to cause a significant reduction in tear production were included in this study. The exclusion criteria were,
and adversely affects corneal sensitivity and ocular surface.19 all other forms of glaucoma like primary angle-closure
Brimonidine also has good safety and tolerability but glaucoma (PACG), secondary glaucoma, presence of active
higher incidence of conjunctival hyperemia and allergic ocular inflammation or allergy, any ocular pathology which
conjunctivitis.20-22 Considering the unfavorable effects can disrupt ocular surface (entropion, ectropion, pterygium,
with current glaucoma medications, patient compliance concretions, chalazion), ocular trauma, symptoms and
and tolerability are affected adversely due to which newer any treatment of prior dry eye (punctual plugs, topical
molecules and drug delivery systems are being researched.23 corticosteroids), patients with history of previous glaucoma
surgery, any surface refractive surgery, contact lens wearers,
In this study, the long-term effects of topical timolol 0.5%, systemic diseases (asthma and cardiac disease), diabetes
brimonidine 0.1%, bimatoprost 0.01% on the ocular surface mellitus, and autoimmune diseases.
and tear film were investigated. Further the effect of
monotherapy vs. dual and triple therapies in patients with The patients were divided into test (patients on topical
glaucoma on ocular surface was evaluated. Since limited antiglaucoma drugs) and control group. Test group were
Indian studies are reported in literature comparing the effect subdivided into A1: patients on single antiglaucoma drug
E-ISSN: 2454-2784 P-ISSN: 0972-0200 45 Delhi Journal of Ophthalmology
DJO Vol. 32, No. 3, January-March 2022
either timolol 0.5%, brimonidine 0.1%, or bimatoprost Mann-Whitney U test (for comparison between test and
0.01%; A2: patients on dual combination of any of the two control group), depending upon distribution of the data.
antiglaucoma drugs mentioned in A1 group; and A3: patients Comparison of continuous variables between three or more
on triple antiglaucoma drug combinations mentioned in groups (i.e. Group A1, A2, and A3) was made using one-
A1 group. The groups A2 and A3 were prescribed with way ANOVA or Kruskal-Wallis test depending upon the
drug combinations rather than multiple separate drug distribution of data. If a statistically significant difference was
preparations. The control group included patients with found (p<0.05), a post-hoc multiple comparison procedure
newly diagnosed of POAG (with no past history of topical (Tukey test) was used to compare each group. Statistical
antiglaucoma medications). analyses were performed using the Statistical Package for
Social Sciences version 20.0 (IBM Corp, Armonk, NY).
Patient examination was conducted for visual acuity (on
Snellen’s chart), best corrected visual acuity, slit lamp Results
examination, applanation tonometry to measure IOP,
gonioscopy with Goldman single mirror lens, fundus A total of 164 patients were enrolled in this study, of these, 109
examination with +90D lens slit lamp biomicroscopy, patients were included in the test group (A) while 55 patients
Humphrey visual 30-2 for tear break-up time test (TBUT), were included in control group. Test group was further
rose bengal staining of ocular surface, conjunctival subdivided as A1, A2, and A3, according to the number
impression cytology, Schirmer’s -I test and ocular surface of antiglaucoma drugs being used. The demographics of
disease index (OSDI) questionnaire study. the subjects are summarized in (Table 1). Ocular surface
disease was evaluated according to the number of eyes that
The Schirmer-1 test was performed without anesthesia is 218 cases and 110 control, considering that two eyes have
by placing a standardized strip of filter paper (Whatman different base line IOP and slightly different morphology.
filter paper no.41) in the one-third lateral tarsal conjunctiva There was a significant difference in mean Schirmer’s test
away from the cornea. The TBUT test was performed by
applying fluorescein solution onto the inferior palpebral Table 1: Patient demographics
conjunctiva after gentle depression of the lower eyelid. A
clinically abnormal TBUT was defined as less than or equal Parameters A1 (n=40) Test A3 (n=19) Control
to 10 seconds.24 Rose bengal (1%, 2µL) was instilled into the 51.88 (10.40) A2 (n=50) 55.00 (9.82) (n=55)
conjunctival sac. The dye stained all eroded and denuded Age, mean 53.20 (9.02)
areas of the corneal and conjunctival epithelial cells.25 (SD) 17 (42.50) 54.44 (8.69)
Sex Men 23 (57.50) 28 (56.00)
In conjunctival impression cytology of the ocular surface, SexWomen 22 (44.00) 8 (42.11) 23 (41.82)
a 25 mm diameter nitrocellulose membrane filter (filter 11 (57.89) 32 (58.18)
type 0.22 μm; GSWP, Merck Millipore, Billerica, MA, USA)
was cut into half and trimmed into strips of approximately Data shown as n (%), unless otherwise specified. SD, standard
4×6 mm. After instillation of one to two drops of topical deviation.
anesthetic (Alcaine; Alcon, Puurs, Belgium) and wiping
away the excessive tear fluid, the strip of filter paper was results between the groups (p<0.001). The mean Schirmer’s
gently pressed on the conjunctiva with a glass rod. After test (mm) was 15.06, 13.77, 11.24, and 21.26 in A1, A2, A3 and
5-10 seconds, the filter paper was peeled off and the cells control group, respectively. The mean of TBUT (seconds)
were transferred by imprinting onto poly-L-lysine-coated was 9.84, 8.25, 5.29 and 12.33 in A1, A2, A3 and control group,
glass slides. Specimens were collected from the inferior and respectively. The mean rose bengal was more common in
temporal bulbar conjunctiva of the selected study.26 The A3 (5.92) followed by A2 (3.94), A1 (2.55) and control group
slides were air-dried and stained with hematoxylin and (1.21). The subgroup differences were statistically significant
eosin stain. Specimens were analyzed by light microscopy (p<0.001). There was a significant difference between the
using modified Nelson’s grading scheme (grades 0-3) based mean conjunctival impression cytology grades of subgroups
on the appearance of epithelial cells and the density of goblet A3 (2.74), followed by A1 (1.83) and A2 (1.70) compared
cells.27 Grades 0 and 1 are present in normal conjunctiva to control group (0.96; p<0.001) (Table 2). The mean OSDI
with nucleus-to-cytoplasm (n/c) ratio up to 1:3, whereas scores were significantly high in subgroups A2 (34.62)
grades 2 and 3 are abnormal (n/c ratio >1:4) and indicate and A3 (49.63) compared to A1 (25.93) (p<0.001). Ocular
squamous metaplastic changes seen in many inflammatory surface disease increases with the increase in the duration
conditions (dry eye, use of antiglaucoma therapy, contact of medications (A1 [5.10], A2 [6.62], and A3 [13.16] months;
lens wearers). All the patients completed OSDI which is a 12- p<0.001) (Table 2).
item questionnaire designed to provide a rapid assessment
of the symptoms of ocular irritation consistent with dry eye The number of eyes in the test group who had abnormal
disease and their effect on vision related functioning.28 Schirmer’s tests was significantly more than control group
(59.17% vs. 4.55%, p<0.001). The percentage of prevalence
Statistical analysis with abnormal TBUT (seconds), rose bengal (grade) staining
and impression cytology was significantly more common
Categorical variables were presented as proportions and in the test group (66.06%, 63.30%, and 72.48%, respectively)
compared using Pearson’s Chi-square test. Continuous compared to control group (p<0.001). The OSDI score was
variables were presented as mean (standard deviation) or also significantly higher in test group (63.76% vs. 9.09%;
median and range and compared using Student’s t-test or p<0.001) (Table 3). The number of eyes with abnormal OSD
tests were significantly high in test group compared to the
control group (p<0.001) (Table 4).
E-ISSN: 2454-2784 P-ISSN: 0972-0200 46 www.djo.org.in
DJO Vol. 32, No. 3, January-March 2022
Table 2: Summary of results Therefore, considering these factors, the marketed drug
formulations which contain same preservatives have been
Parameters Test Control P used in this study.
A2 (n=100) (n=110) value
The major findings in this study reveal that chronic use
A1 A3 (n=38) of commercial preparations of timolol, brimonidine and
(n=80) bimatoprost are associated with conjunctival changes
Schirmer’s 13.77 (3.11) 11.24 21.26 <0.001 leading to damaged ocular surface. Patients enrolled in this
test (mm) 15.06 8.25 (2.31) (4.38) (4.01) <0.001 study used single as well as dual and triple combination
TBUT (s) (3.18) 3.94 (1.86) 5.29 (1.83) <0.001 therapies. The severity of OSD was higher in combination
12.33 drugs than a single drug. Patients with POAG showed
Rose bengal 9.84 5.92 (1.92) (2.20) associated OSD with abnormal tear production and quality
(grade) (2.05) that is in accordance with the reported Indian and global
1.21 studies.28,32,33 Previously reported clinical studies report that
2.55 (0.46) long-term usage of topical anti-glaucoma drugs adversely
(1.33) affect the ocular surface.13,34,35 Studies show that the
conjunctival surface and tear film function is damaged due
Impression 1.83 1.70 (0.70) 2.74 (0.45) 0.96 <0.001 to long term use of timolol, brimonidine and bimatoprost
(0.60) as well as with other combinations of beta-blocker, alpha
cytology (0.82) adrenergic agonist, and prostaglandin analogue. However,
there is a paucity in studies reporting the effect of timolol,
OSDI score 25.93 34.62 49.63 19.93 <0.001 brimonidine and bimatoprost monotherapy and their fixed
(7.69) (10.86) (5.12) (5.38) drug combinations on ocular surface; hence this study was
[n=40] [n=50] [n=19] [n=55] undertaken to determine the comparative effect of long-term
usage of these drugs.
Duration 5.10 6.62 (2.47) 13.16 - <0.001
of drugs (1.69) [n=50] (3.95) Although men are more prone to POAG [36,36], the present
(months) [n=40] [n=19] study showed women predominance who were in their mid-
fifties and this concurs with previously reported studies.33,38
Data shown as mean (SD). The ocular surface changes evaluated using Schirmer’s test,
n= Total number of eyes TBUT, rose bengal staining and impression cytology showed
mm, millimeter; OSDI, ocular surface disease index; SD, standard higher abnormality in the test group than the control group.
deviation; TBUT, tear film breakup time.
Investigations reveal that preserved eye formulations
Table 3: Prevalence of OSD in patients on antiglaucoma drugs cause eye irritation symptoms and adverse effects more
than those without preservative.39 Benzalkonium chloride
Parameters Test Control P value is the most commonly used preservative in the topical
(n=218) (n=110) antiglaucoma formulations. Studies report cytotoxicity and
proinflammatory effects on the ocular surface, squamous
Schirmer’s test (mm) 129 (59.17) 5 (4.55) <0.001 metaplasia of conjunctiva and decrease in the goblet cell
number.40-42 The recently introduced polyquaternium
TBUT (s) 144 (66.06) 6 (5.45) <0.001 preservative is observed to increase cell death and production
of proinflammatory cytokines in human corneal epithelial
Rose bengal (grade) 138 (63.30) 2 (1.82) <0.001 cell culture.43
Impression cytology 158 (72.48) 14 (12.73) <0.001 A prospective epidemiological survey conducted in a series
of 4107 patients, studied the ocular toxicity of preservatives
OSDI score 139 (63.79) 10 (9.09) <0.001 present in glaucoma medications. The study demonstrated
that 84% patients used preserved eye drops that showed more
Data shown as n (%). prevalent but reversible adverse reactions induced by these
n= Total number of eyes medications compared to preservative free medication.41
OSDI, ocular surface disease index; TBUT, tear film breakup time.
The mean Schirmer’s test results showed a significant low
Table 4: Number of positive OSD test in test and control eyes value in the antiglaucoma subgroups when compared to that
of control group. These results are in line with the results
Tests Test (n=218) Control (n=110) P value of previously reported studies.43 Saini M et al. conducted a
prospective comparative study of ocular surface evaluation
0 20 (9.17) 94 (85.45) on 50 eyes using antiglaucoma medications vs. 50 normal
eyes that showed a significantly low mean Schirmer’s test
1 42 (19.27) 6 (5.45) score in antiglaucoma eyes than the normal eyes (7.63 [2.64]
vs. 12.86 [1.93]; p<0.001).33
2 16 (7.34) 4 (3.64) <0.001
3 12 (5.50) 3 (2.73)
4 42 (19.27) 1 (0.91)
5 86 (39.45) 2 (1.82)
Data shown as n (%). OSD, ocular surface disease.
The OSD tests include Schirmer’s test, tear film break
up time (TBUT), Rose Bengal, Impression cytology, and
ocular surface disease index (OSDI) score.
Discussion
Various experimental and clinical studies have shown that
the use of topical antiglaucoma drugs and preservatives
present induce mild to severe discomfort due to ocular
surface changes. Hyperemia, conjunctival inflammation
and fibrosis, dry eye syndrome, eyelid dermatitis, tear
film instability and impaired cornea occur commonly.29-31
E-ISSN: 2454-2784 P-ISSN: 0972-0200 47 Delhi Journal of Ophthalmology
DJO Vol. 32, No. 3, January-March 2022
In the present study, the mean TBUT reported a significantly This study has limitations like the effect of individual
less time in glaucoma treated subgroups compared to the antiglaucoma drug on ocular surface was not compared,
control group. Also, the mean TBUT in all the subgroups other types of glaucoma apart from POAG were not
was less than 10 seconds indicating tear instability while included, and sample size. A larger scale prospective study
the control group reported a mean TBUT of 12.33 seconds may possibly give a better understanding about the changes
indicating a better ocular surface compared to the former. in ocular surface during course of disease.
Investigations report a break-up time of <7 seconds (n=79
and n=18) patients with POAG.26,44 A cross-sectional case To conclude, this study firmly emphasizes that long term
comparison study demonstrated that the percentage of topical antiglaucoma drugs are associated with mild to
abnormal TBUT was rising with the number of topical severe form of OSD. This can occur with multiple drugs or
medications and was significantly higher with both single drug, if used for more than three months, although the
benzalkonium chloride-containing and preservative-free eye degree of severity may vary. Therefore, it is recommended
drops (90% and 94%, respectively, both p<0.001).24 that every patient with POAG visiting the clinic and are
administering prolonged topical IOP lowering drugs,
A prospective cross-sectional study in 109 Thai patients should be screened for OSD. Along with antiglaucoma
receiving topical IOP lowering therapy revealed that rose therapy, these patients require management of OSD as well.
bengal staining was positive in 39% patients with glaucoma. This will help in reducing the patient’s discomfort and will
A number of IOP-lowering eye drops was associated surely improve the compliance of the treatment, which is a
with 4.4 times significantly higher odds of abnormal rose very important aspect of glaucoma management.
bengal staining (95% CI, 1.91-10.32, p=0.001).5 Fluorescein
staining was also reported by 32% patients which was not Reference
performed in the current study. The present study also
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12. European glaucoma society terminology and guidelines
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16. Sawada A, Yamamoto T. Switching efficacy on intraocular
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