dos_oct_2013

Miscellaneous

6. The previous segment location before the frame allows you to educate the customer on the
Some general guidelines to follow when showing frames different types of lenses and lens enhancements available,
to patients: then determine which frames can accommodate the lenses
1. The frame-front width should be approximately the chosen.
Often the patient has not considered the lenses or their cost.
width of the patient’s head. If the frame is selected first, the patient may be inclined to
2. Eyes should be positioned in the central part of the settle for lenses that are less than what is recommended,
which can result in reduced visual performance and lens
frame-front eyewire. cosmetics and, ultimately, a dissatisfied customer2.
3. For plastic frames, the bridge shape should contour to Review
1. Follow manufacturer recommendations when
the nose shape.
4. Adjustable pads should provide even pad contact on dispensing lenses and frames.
2. Check the front first. The frame front should be
the nose.
5. The temple length should allow a temple bend length positioned so the eyes are level in the eyewire.
3. Observe if the bottom or top of the frame is too close
of 1 to 1-1/4 inches.
The doctor’s prescription, or Rx, is the window to patient’s to the face. Check the pantoscopic angle of the frame
visual needs. Though the numbers and letters on the form from the side.
are only a small part of the overall vision examination, 4. Observe the distance of the frame front to the eyes at
the information on the prescription, combined with your the top and bottom of the frame. The distance should
knowledge, will allow you to guide the customer in the equal.
proper selection of frames and lenses. 5. There should be no side pressure from the temples
The major areas of the prescription form are: before the ear. The temples should run back touching
1. Patient’s name and address but not creating pressure. Side bow if necessary.
2. Date of eye exam 6. The temple bend at the top of the ear should be made
3. Distance vision prescription for right eye about 1/4-inch behind the ear.
4. Distance vision prescription for left eye 7. Contour the temple from the top bend to the tip to
5. Near Vision, Add Power for right and left eyes create friction.
6. Remarks – additional information 8. Check the overall fit for comfort and snugness.
7. The doctor’s signature References
Additional areas may be printed on the form to meet the
needs of your hospitals/centres 1. Keay L, Friedman DS. Correcting refractive error in low income
In the dispensing area, two major decisions will be finalized: countries (editorial). BMJ. 2011. 343: d4793.
the selection of lenses and the selection of frame(s). Eyecare
professionals tend to agree it is best to determine the lens 2. Zhang M, Zhang R, He M, et al. Self correction of refractive error
selection first, then the frame selection. Choosing the lenses among young people in rural China: results of cross sectional
investigation. BMJ L. 2011. 343: 407.

www. dosonline.org l 61

Evolution of Ocular Evolution
Surface Transplantation
Tarun Arora
MD

Tarun Arora MD

Rajendra Prasad Centre for Ophthalmic Sciences,
All India Institute of Medical Sciences, New Delhi

The management of severe ocular surface disease (OSD) (Figure 1) His technique was based on the principle of
has benefited from major breakthrough in recent conjunctival transdifferentiation, which postulated that the
years. Previously patients with OSD had a poor prognosis. conjunctival epithelium could transform into cornea-like
Modern treatment of severe ocular surface disorder is quite epithelium2. In his report of 22 eyes, 19 obtained a good
different. Advancements in microsurgical techniques and ocular surface, out of which two subsequent keratoplasties
understanding of the role of limbal stem cells have led went on to fail. Although a conjunctival autograft is useful
to great improvement in both visual acuity and patient`s in reestablishing an intact ocular surface in patients with
quality of life. It is very interesting to study the sequence conjunctival scarring, concerns exist as to whether this
of events that led to the birth of modern day regenerative procedure truly results in normal corneal epithelium3. The
medicine in ocular surface reconstruction. technique of conjunctival autograft remains a valuable
Conjunctival transplantation procedure for the management of fornix reconstruction as
In 1977, Thoft described the conjunctival transplantation well as primary and recurrent pterygium.
procedure, which is recognized as the forerunner of modern Keratoepithelioplasty
ocular surface transplantation1. Thoft reported transplanting In 1984, Thoft described the first allograft procedure for
several pieces of bulbar conjunctival tissue from a normal the management of severe OSD. (Figure 2) He called the
fellow eye to four quadrants of the eye with damaged procedure keratoepithelioplasty (KEP)4. His procedure
ocular surface epithelium and superficial vascularization. involved the use of lenticules of peripheral cornea from a
An epithelial front spread onto the corneal surface from the cadaveric donor cornea as a source of epithelium. A whole
edges of each graft during the reepithelialization process. globe was used to obtain four pieces of partial thickness

1(a) 1(b) 2(a) 2(b)
Figure 1: Thoft’s conjunctival autograft. (a): Grafts are taken from uninjured fellow eye in four
quadrants from areas normally covered by eyelid. (b): Placement of conjunctival grafts.
Figure 2: Thoft’s keratoepithelioplasty. (a): Preparation of lenticules from donor globe.
(b): Placement of lenticules around the corneoscleral limbus.
www. dosonline.org l 63

Evolution

Cresentric conjunctival-limbal Suture limbal
biopsies from fellow eye biopsies in place

Conjunctival
Limbal

Autograft

Suture
amniotic
membrane
to sclera in
4 quadrants

Figure 3: Kenyon and Tseng’s conjunctival autograft. Bulbar conjunctival portion of the autograft is undermined and thinly dissected
free from its limbal attachments. The limbal autografts are transferred to their corresponding sites in the recipient eye

cornea. Lenticules were carved from the midperipheral keratin expression and discovered that the corneal limbus
cornea and consisted of an epithelium and a thin layer basal cells are less differentiated than those found in other
(0.2mm) of stroma that served as a carrier for delicate areas of the corneal epithelium. Cotsarelis and co-workers8
epithelium. The four lenticules were placed evenly around provided additional evidence that stem cells were located
the corneoscleral limbus and sutured to the sclera. No at the limbus when they found that tritiated thymidine was
limbal cells were used in this technique. The epithelium incorporated for long time intervals into limbal basal cells.
from the lenticules spread and covered the recipient This labeling indicated that these cells exhibited a long cell
cornea. Because cadaveric eyes, rather than the fellow eye, cycle. Ebato and associates9 reported that human ocular
were used for the donor tissue, this technique was useful limbal epithelial cells grew better in culture and had higher
in treating patients with bilateral OSD. Although Thoft did rates of mitotic activity than peripheral corneal epithelial
not describe obtaining limbus with his KEP procedure, cells.
since there was not a good understanding of the stem cell Limbal Autograft
theory at that time, it is possible that some stem cells were In 1989, Kenyon and Tseng10 were the first to take the
harvested with the peripheral corneal lenticules. In 1990, limbal stem cell theory and apply it clinically. They built on
Turgeon and co- workers, including Thoft, reported on the work of Thoft by modifying his conjunctival autograft
13 additional patients managed with KEP5. The technique surgery to include limbal stem cells. In this way, their
described was modified from Thoft’s original procedure procedure was the first to specifically transplant limbal
to include limbal tissue with the peripheral corneal tissue epithelial stem cells for severe OSD. In this procedure,
in an attempt to transplant limbal stem cells. Of the 11 conjunctival and limbal tissue from a normal fellow eye was
patients with at least 6 months’ follow-up, 7 had a stable used to manage diffuse limbal deficiency in unilateral ocular
ocular surface, and 7 had improved visual acuity. surface disease, or focal limbal deficiency in unilateral or
Limbal Stem Cell Theory bilateral disease (Figure 3). Their technique used grafts of
The single most important breakthrough in managing bulbar conjunctiva that extended approximately 0.5 mm
severe OSD was the understanding of the location and onto the clear cornea centrally, thus containing limbal
function of the limbal stem cells. In 1971, Davenger and cells. The authors reported data on 21 cases with 6 months
Evenson6 speculated that the source for replacing the or more of follow-up. The results were impressive with
corneal epithelium lay at the limbus when they observed rapid surface healing in 19 cases, stable ocular surface in
that pigmented limbal cells moved centrally. Schermer 20 cases, improved visual acuity in 17 cases, and arrest
and co-workers7 studied patterns of cornea- specific 64K of regression of corneal neovascularization in 15 cases.

64 l DOS Times - Vol. 19, No. 4 October, 2013

Evolution

No complications developed in the donor eyes. Seven Trim excess Trephine used to remove central
of seven patients underwent simultaneous or subsequent sclera from corneal from corneal scleral rim
successful penetrating or lamellar keratoplasty. A potential limbal ring
risk of limbal autograft transplantation is development of Trim
iatrogenic limbal stem cell deficiency in the donor eye. A posterior
recent study has shown that partial removal of full-thickness surface of
limbal zone will compromise the donor surface11. limbal graft
Keratolimbal Allograft (KLAL) with scissors
Tsai and Tseng reported a modification of Thoft’s
keratoepithelioplasty procedure in 199412. They described Keratolimbal Allograft
an “allograft limbal transplantation” procedure that
utilized a whole globe to provide a keratolimbal graft Keratolimbal placed on top of
(Figure 4). A suction trephine was used to make mid- Allograft amniotic membrane
peripheral and scleral incisions, resulting in a continuous
ring of keratolimbal tissue. The resultant keratolimbal (ring technique)
ring was divided into three equal pieces and transferred
to the recipient eye. Postoperatively, all patients were Eight sutures
treated with oral cyclosporin A (CsA) in addition to topical used to secure
corticosteroids. In 1995, Tsubota and colleagues reported donor allograft
a technique they termed “limbal allograft transplantation”,
another variation of a keratolimbal allograft13. Their to sclera
technique was the first report of using stored corneoscleral
rims for stem cell transplantation. By using stored tissue, Figure 4: Allograft keratolimbal transplantation
they afforded patients several days with which to co- procedure utilizing a whole globe to provide a
ordinate surgery after acquisition of suitable donor tissue.
The major disadvantage of keratolimbal allograft is the high keratolimbal graft
risk of rejection. Intensive immunosuppression by systemic
corticosteroids and systemic and topical cyclosporine A of tissue that can be transplanted from the living donor is
was reported to improve the survival of limbal allografts and limited to only 2 clock hours of limbal conjunctival tissue at
is recommended when performing KLAL and peneterating the 12 and 6 o’clock positions from each eye, to minimize
keratoplasty (PKP). the risk of developing limbal deficiency in the donor.
Living-Related Conjunctival Allograft Human Amniotic Membrane Transplantation
In 1995, Kwitko and co-workers described a technique Further strategies to reconstruct the ocular surface
called allograft conjunctival transplantation14. In this report, have included the use of human amniotic-membrane
they were the first to utilize a living relative as a source of transplantation (AMT). In 1940, de Rötth reported the
donated ocular surface tissue. They harvested conjunctival successful use of amniotic membrane transplant for
tissue, and made a specific point of stating that they did not conjunctival reconstruction in 1 of 6 patients following
transplant limbal tissue. Donor conjunctiva was obtained chemical burn injury. The reconstructed tissue in this
from siblings, and if tissue could not be obtained from a patient was histologically similar to the normal bulbar
sibling, a parent was used. Kenyon and Rapoza described conjunctiva16. In 1995, Kim and Tseng used amniotic
a technique they called limbal allograft transplantation in membrane for ocular surface reconstruction in a rabbit
which they trans- planted limbal tissue with a conjunctival model of OSD17. In their studies, they demonstrated that
carrier from a living related donor15. This technique AMT facilitated epithelialization without allowing host
was similar to Kenyon and Tseng’s technique of limbal fibrovascular ingrowth onto the membrane, and suggested
autograft, except that the donor tissue was obtained from a that this procedure might be clinically useful for ocular
living relative as opposed to the fellow eye. This technique surface reconstruction. Following on this work, in 1996
differs from Kwitko’s living related conjunctival allograft Tsubota and co-workers were the first to reconstruct
technique in that Kenyon and Rapoza transplanted limbal human eyes with severely diseased ocular surfaces and
tissue along with conjunctival. limbal deficiency utilizing AMT18. They combined AMT
The use of living-related conjunctival allografts may with a limbal stem cell allograft in 14 eyes of 11 patients
minimize the risks of rejection associated with the use of with Stevens–Johnson syndrome and ocular cicatricial
unrelated cadaveric donor tissue. However, the amount pemphigoid. Human amniotic-membrane transplantation
is useful in conjunction with epithelial transplantation
because it promotes epithelial growth without fibrovascular
growth and reduces ocular surface inflammation. It supports
differentiation of epithelial cells, is nonantigenic, and is
resorbed in vivo.

www. dosonline.org l 65

Evolution

(a) (b) available, and all received systemic immunosuppression.
Eight eyes survived24.
Figure 5: Ex vivo expansion of limbal stem cells from limbal
biopsy. (a): Culture plate with the tightened amniotic membrane Cultivated oral mucosal epithelial transplantation
(COMET)
and a limbal biopsy placed in the center (arrows). (b): Phase- Studies have shown that oral epithelial cells can be cultured
contrast microscopy of the expanded cells reveals a monolayer of and used as an alternative for allogenous limbal transplants
in case of bilateral LSCD. Cultivated mucosal epithelial
epithelial cells of small and uniform size transplantation25 using well-differentiated, stratified
epithelial sheets on amniotic membrane allows a rapid re-
Ex Vivo Expansion of Limbal Stem Cells epithelial cover over the entire corneal surface, resulting
In 1997, Pellegrini and co-workers described a procedure in early reduction of inflammation and cicatrization. This
using autologous cultivated corneal epithelium to restore surgical approach dramatically improves the prognosis
the ocular surfaces of two patients with unilateral alkali of severe ocular surface diseases, especially severely
injury19. They based their procedure on tissue culture work inflamed corneal stem cell deficiency. This new approach
that had been done by Lindberg and co-workers in 199320. not only provides early epithelialization but also allows
Pellegrini’s group used a 1–2 mm two full-thickness limbal reconstruction of the corneal surface using autologous
specimen from the healthy fellow eye to create sheets of cultivated epithelium including the cornea and oral mucosa
corneal epithelial cells in tissue culture. These epithelial from a small number of cell sources after amplification.
sheets were then transplanted to the injured eye. Both
patients were followed for more than two years, and both The Use of Autologous Serum in the Development
retained a stable ocular surface, implying that stem cells of Cultivated Epithelial Sheets
had been transplanted. In 2000, Tsai and co-workers21 and The currently preferred method of cultivating epithelial
Schwab and co- workers22 separately published their results sheets requires the use of xenobiotic materials in the
using ex vivo expanded limbal stem cells grown on human culture system, such as fetal bovine serum (FBS) and mouse-
amniotic membrane (Figure 5). Tsai’s group expanded derived 3T3 feeder cells. However, the use of FBS in the
limbal epithelium on human amniotic membrane prepared culture system is a major concern, as bovine spongiform
as described by Lee and Tseng, and six eyes of six patients encephalopathy cannot be detected by any known in vitro
showed epithelialization within four days. Schwab’s group assay. Various serum-free culture systems, developed to
grew harvested limbal stem cells on human amniotic delete the FBS from the culture system, have mainly been
membrane that had been denuded of native epithelium in used to study the roles of various growth factors. The
a technique described by Schwab the previous year. The clinical use of these serum-free culture systems has been
ocular surface reconstruction was considered successful limited because of their lower efficacy for cell proliferation,
in all allograft patients, and in one of the three-autograft compared to FBS-supplemented medium.
patients. As a much smaller amount of limbal tissue is
obtained from the donor eye than is required for performing Future goals
conjunctival limbal auto- or allografting, it minimizes In view of the basic research and developments in the
potential future complications to the healthy donor eye. field of regenerative medicine for OSR, both past and
Systemic Immunosuppression present, great progress has been made in the fundamental
Another important advancement in the evolution of understanding and development of a new therapeutic
ocular surface transplantation is the use of systemic modality, such as the transplantation of cultivated oral
immunosuppression. Rao and co-workers reported 9 eyes mucosal epithelial sheets using tissue engineering
of 8 patients who underwent living- related conjunctival techniques. Greater knowledge regarding epithelial stem
limbal allograft. All received the best HLA match available. cell behavior from non-ocular sources and the surrounding
Systemic immunosuppression was not used, and all ocular extracellular matrix will provide a foundation for the further
surfaces went on to fail. The authors felt that the cause of development of treatments for severe OSD.
ocular surface failure was secondary to immune-mediated
rejection23. Daya et al presented a series of patients with Refrences
living- related conjunctival limbal allograft. He described
10 eyes of 8 patients. All received the best HLA match 1. Thoft RA. Conjunctival transplantation. Arch Ophthalmol.
1977;95:1425–27.

2. Huang AJW, Watson BD, Hernandez E, et al. Photothrombosis of
corneal neovascularization by intravenous rose bengal and argon
laser irradiation. Arch Ophthalmol. 1988;106:680–685.

3. Harris TM, Berry ER, Pakurar AS, et al. Biochemical transformation
of bulb conjunctiva into corneal epithelium: an electrophoretic
analysis. Exp Eye Res. 1985;41:597–605.

66 l DOS Times - Vol. 19, No. 4 October, 2013

Evolution

4. Thoft RA. Keratoepithelioplasty. Am J Ophthalmol. 1984;
97:1–6. 17. Kim JC, Tseng SCG. Transplantation of preserved human amniotic
5. Turgeon PW, Nauheim RC, Roat MI, et al. Indications membrane for surface reconstruction in severely
damaged rabbit
corneas. Cornea 1995;14:473–84.
for
keratoepithelioplasty. Arch Ophthalmol. 1990;108:33–36.
6. Davanger M, Evensen A. Role of the pericorneal papillary structure 18. Tsubota K, Satake Y, Ohyama M, et al. Surgical reconstruction of
the ocular surface in advanced ocular cicatricial pemphigoid and
in renewal of corneal epithelium. Nature 1971;229:560–561. Stevens–Johnson syndrome. Am J
Ophthalmology 1996; 122:38–
7. Schermer S, Galvin S, Sun T-T. Differentiation-related ex
pression of 52.

a major 64K corneal keratin in vivo and in culture suggests limbal 19. Pellegrini G, Traverso CE, Franzi AT, et al. Long-term
restoration
location of corneal epithelial stem cells. J Cell Biol. 1986;103:49– of damaged corneal surfaces with autologous
cultivated corneal
62. epithelium. Lancet 1997;349:990–3.
8. Cotsarelis G, Dong G, Sun T-T, et al. Differential response of limbal
and corneal epithelial to phorbol myristate acetate (TPA). Invest 20. Lindberg KL, Brown ME, Chaves HV, et al. In vitro propagation of
Ophthalmol Vis Sci. 1987;28:1. human ocular surface epithelial cells for trans-
plantation. Invest
9. Ebato B, Friend J, Thoft RA. Comparison of limbal and peripheral Ophthalmol Vis Sci. 1993;34:2672–2679.
human corneal epithelium in tissue culture. Invest Ophthalmol Vis
Sci. 1988;29:1533–1537. 21. Tsai RJ-F, Li L-M, Chen J-K. Reconstruction of damaged corneas by
10. Kenyon KR, Tseng SCG. Limbal autograft transplantation for ocular transplantation of autologous limbal epithelial
cells. N Engl J Med.
surface disorders. Ophthalmology 1989;96:709–23. 2000;343:86–93.
11. Chen JJ, Tseng SC. Corneal epithelial wound healing in partial
limbal epithelium. Invest Ophthalmol Vis Sci. 1990;31:1301–1314. 22. Schwab IR, Reyes M, Isseroff RR. Successful transplanta
tion of
12. Tsai RJF, Tseng SCG. Human allograft limbal transplantation for bioengineered tissue replacements in patients with ocular surface
corneal surface reconstruction. Cornea 1994;13:389–400. disease. Cornea 2000;19:421–6.
13. Tsubota K, Toda I, Saito H, et al. Reconstruction of the corneal
epithelium by limbal allograft transplantation for severe ocular 23. Rao SK, Rajagopal R, Sitalakshmi G, Padmanabhan P. Limbal
surface disorders. Ophthalmology 1995;102:1486–1495. allografting from related live donors for corneal surface
14. Kwitko S, Raminho D, Barcaro S, et al. Allograft conjunctival reconstruction. Ophthalmology 1999;106:822–828.
transplantation for bilateral ocular surface disorders. Ophthalmology
1995;102:1020–1025. 24. Daya SM, Living-related conjunctivo-limbal allograft (lr-CLAL) for the
15. Kenyon KR, Rapoza PA. Limbal allograft transplantation
for ocular treatment of stem cell deficiency: an analysis of long-term outcome.
surface disorders. Ophthalmology 1995;102:101–2. Ophthalmology 1999; 106:243.
16. De Rotth A. Plastic repair of conjunctival defects with fe
tal
membrane. Arch Ophthalmol. 1940;23:522–25. 25. Inatomi T, Nakamura T, Koizumi N, et al. Current concepts and
challenges in ocular surface reconstruction using cultivated mucosal
epithelial transplantation. Cornea 2005;24:32-38.

www. dosonline.org l 67

Ocular Chemical PG PCGoCronrneer
Injuries
Sandeep Gupta
Sandeep Gupta MS MS
Rajendra Prasad Centre for Ophthalmic Sciences,
All India Institute of Medical Sciences, New Delhi

The most common and probably the only true ocular • Acid injuries decrease the pH causing coagulation and
emergency is chemical injury of the eye. Immediate precipitation of proteins, thus limiting the penetration
assessment and treatment is the single most important and damage. However strong acids lead to rapid
determinant of final functional acuity and morbidity of the disorganisation and destruction of whole globe.
injured eye.
Common agents causing chemical injuries 2. Proteolysis
1. Alkalies • Release of various proteolytic enzymes by neutrophils
• Lime, present in edible chuna and materials used
and epithelial cells leads to stromal ulceration.
in white washing. 3. Collagen effects
2. Acids • Damage to ciliary body which is more common with
• Toilet cleaners.
• Used in various labs, small and large scale alkali burns leads to decreased production of ascorbate
which affects glycosaminoglycans and collagen
industries. synthesis. This leads to stromal ulceration.
3. Thermochemical injuries
• Fire cracker injuries. Figure 1: Ocular chemical injury with 2700 limbal
• Blast injuries. stem cell deficiency before surgery
• Electric burns.
Mechanism of injury
The injury can be to face, eyelids, and conjunctiva and
to the cornea. However, in severe cases the whole globe
can be rapidly disorganised. The most severe and visually
significant changes occur at the level of ocular surface and
at the cornea by the following mechanisms.
1. pH changes
• Increase in pH due to alkali injuries cause saponification

of fatty acids of cell membranes leading to cell
destruction and deeper penetration of alkalis. Hence,
the alkali injuries are more destructive.

www. dosonline.org l 69

PG Corner

Table 1: Classification of ocular surface burns (HARMINDER S DUA, ANTHONY J KING and ANNIE JOSEPH)

Grade Prognosis Clinical findings Conjunctival Analogue scale*
involvement

I Very good 0 clock hours of limbal involvement 0% 0/0%

II Good <3 clock hours of limbal <30% 0.1–3/1–29.9%
involvement

III Good >3-6 clock hours of limbal >30-50% 3.1–6/31–50%
involvement

IV Good to guarded >6-9 clock hours of limbal >50-75% 6.1–9/51–75%
involvement (Figure 1)

V Guarded to poor >9<12 clock hours of limbal >75<100% 9.1–11.9/75.1–99.9%
involvement

VI Very poor Total limbus (12 clock hours) Total conjunctiva 9.1–11.9/75.1–99.9%
involved (100%) involved

*The analogue scale records accurately the limbal involvement in clock hours of affected limbus/percentage of conjunctival involvement.

• Coagulation of proteins with acids injuries causes Figure 2: Optical rehabilitation in the form of lamellar
collagen shrinkage and rapid increase in Intraocular keratoplasty and AMG
pressure (IOP).
• Amphoteric substances like Diphoterine and
4. Raised IOP Hexafluorine (Prevor Labs) can be used in irrigating
• Collagen shrinkage solutions as they can neutralize both acid and bases.
• Protaglandin release
• Inflammatory product accumulation in anterior • Superior and inferior cul de sacs should be examined
after proper anaesthesia with the help of lid retractors
chamber for the presence of any particulate matter which should
Clinical assessment: Done after emergency treatment and be removed. Lime particles can be removed easily after
stabilization (Table 1). irrigation with 0.01M of EDTA solution.
• Visual acuity.
• Epithelial defect- documented after fluorescein staining. • Raised IOP if not managed medically, can be controlled
• Stromal opacity- graded from 0 to 5. by bevelled paracentesis at limbus.
• Perilimbal ischemia- seen as area devoid of blood
Acute phase treatment-
vessels, white in colour. Acute stage lasts up to first 10 days and is characterised
• Conjunctival involvement. by epithelial defects, acute inflammation, pH alteration
• IOP. with decrease in glucose & ascorbate levels in aqueous and
• Ocular adnexa. raised IOP. The treatment is directed towards these effects.
• Lens and posterior segment.
Management
Immediate/ Emergency treatment
• Immediate irrigation of the eye with any non toxic

liquid like Isotonic solutions like ringer lactate or
isotonic saline or tap water is the single most important
step. The eye should be irrigated for a minimum of
30 minutes. It is stopped after the pH of cul de sac
measured with litmus paper returns to normal.
• Attempts to neutralize the initial injuring agent with
acidic or alkali solution is not advocated.

70 l DOS Times - Vol. 19, No. 4 October, 2013

PG Corner

• Topical corticosteroids- used for first 7-10 days - 10% acetyl cysteine,0.2M sodium EDTA and 0.2
reduces inflammatory reaction in the anterior segment. M calcium EDTA also have anti collagenolytic
Prednisolone acetate 1% is given 6 times a day. activity.

• Topical broad spectrum antibiotics, preferably • Continuation of medical therapy.
preservative free, are used in prophylactic dosage to • Conjunctival/ tenon’s advancement to re-establish
prevent infections: Moxifloxacin 0.5% four times a
day. limbal vascularity or to provide tectonic support to
impending perforation.
• Tear substitutes- preservative free drops as • AMG promotes epithelization, reduces inflammation,
carboxymethyl cellulose (CMC) 0.5 and 1% are used vascularisation, scarring and symblepheron formation.
6-8 times a day to promote epithelization. • Treatment of corneal perforation using tissue adhesives,
patch graft of tectonic penetrating keratoplasty.
• Cycloplegics- Atropine 1% / Homatropine 2%, 3 times Rehabilitation
a day is given for cycloplegic effect. aimed at clearing the visual axis by treating limbal stem cell
deficiency with or without an optical procedure.
• Anti glaucoma measures - topical beta blockers, alpha 1. Limbal stem cell transplant
agonists and/or oral and topical carbonic anhydrase • Keratolimbal allograft from cadaveric donor in cases of
inhibitors are used. bilateral involvement.
• Conjunctival limbal autograft from contralateral eye if
• Ascorbate-restores depleted aqueous levels and normal.
prevent corneal thinning and ulceration. Topical 10% • Cultured limbal stem cells with ex vivo expansion of
sodium ascorbate 2 hourly and oral ascorbate 1-2 gms limbal stem cells.
four times a day is started early and given for upto 4 • Simple limbal epithelial transplant- small pieces of
weeks. limbal tissue are transplanted with a carrier tissue as
AMG.
• Other measures to promote epithelization – Bandage • Large diameter lamellar keratoplasty is a single stage
contact lens (BCL), Fibronectin drops, Epidermal procedure which gives tectonic support as well as
growth factor, autologous serum. stem cells for eyes with stem cell deficiency and thin
corneas.
• Early Amniotic membrane grafting (AMG) is advocated 2. Optical procedures following restoration of ocular
by few studies to act as a BCL, reduce inflammation and surface
to prevent symblepheron formation. It can be sutured • Lamellar keratoplasty can give tectonic support as well
to raw conjunctiva, attaché with biological glue or as clear superficial opacities (Figure 2).
used as ready made template in form of Prokera. • Penetrating keratoplasty should be delayed at least 1
year after injury and should be done only after control
Intermediate phase treatment of inflammation and restoration of ocular surface for
This stage lasting from 1-3 weeks is characterised by chances of maximal success.
replacement of destroyed tissue. In severe injuries there • Keratoprosthesis is done in severe injuries in cases
might be a persistent epithelial defect and stromal ulceration where chances of corneal graft survival will be very
due to effect of proteolytic enzymes. The management poor.
involves
• Tapering of steroids as they interfere with repair

process and promote ulceration. If needed, surface
acting steroids as Fluorometholone 0.1% can be used
in 6 hrly dosage.
• Collagenase inhibitors promote wound healing by
inhibiting collagenolytic activity and prevent stromal
ulceration.
- Topical sodium citrate 10% is given 2 hourly for

2-3 weeks.
- Oral Doxycycline 100mg twice a day is also used

for 2-3 weeks.

www. dosonline.org l 71

MonthlyMoMnthelyetMineegtinCg oCronrneer

NSAIDS – A Double Ashish Khindria
Edge Sword MS

Ashish Khindria MS, Jayeeta Bose MS
Venu Eye Institute, Sheikh Sarai, Phase -2, New Delhi

NSAIDs (non-steroidal anti-inflammatory drugs) provide time and had common symptom of poor vision, redness
analgesic and antipyretic effects and in higher doses, and watering. On examination conjunctival congestion,
anti-inflammatory effects. The most prominent members of epithelial defect, infiltrates were seen in each patient.
this group of drugs are aspirin, ibuprofen and naproxen, all One patient had hypopyon and pseudocornea formation.
of which are available over the counter in most countries. NSAIDs were immediately stopped in all the patients and
Prolong use of topical NSAIDs may lead to corneal melting they were started on lubricants & antibiotics.
or non-healing corneal ulcer. Hence they should be used Patient #1
with caution and only when they are required. • 75 yr old lady
They act as nonselective inhibitors of the enzyme • Came with diminution of vision (DOV), pain and
cyclooxygenase (COX), inhibiting both COX-1 and COX-2
isoenzymes1. COX catalyzes the formation of prostaglandins watering in left eye (LE) since 15 days.
and thromboxane from arachidonic acid. Prostaglandins • No history of (h/o) systemic illness and underwent
act as messenger molecules in the process of inflammation
(Table 1). uneventful cataract surgery in LE elsewhere 1 month
Materials and methods back with vision of 6/18.
It is an observational study. Four patients were included in • History of using bromfenac and ketorolac eye drop
the study at the cornea services of a tertiary eye hospital. (e/d) 2 hourly after cataract surgery in same eye.
All patients were using NSAIDs for prolonged period of
Vision • PL+ PR accurate in all quadrants
Table 1: Mechanism of Action of NSAIDS
Lids and conjunctiva • Meibomitis
• Severe congestion

Cornea • Sensations decreased
• Central large epithelial defect

(7x8mm)
• Surrounding ring infiltrates

Fundus • Details not visualized

• Patient was diagnosed as LE neurotrophic ulcer (NSAID
induced)

• Patient was advised stopping of NSAID’s and was
started on:

• Topical prophylactic antibiotics (moxifloxacin
0.5% e/d 4 t/d),

www. dosonline.org l 73

Monthly Meeting Corner

1 2 34

Figure 1: LE neurotrophic ulcer (NSAID induced) (Patient 1)
Figure 2: Cornea showing Ring Infiltrates (Patient 1)
Figure 3: Post trabeculectomy (Patient 2)

Figure 4: Large epithelial defect with 20% to 30% of central stromal thinning (Patient 2)
56

Figure 5: Central stromal thinning (Patient 2)
Figure 6: Large epithelial defect (6x5mm) (Patient 3)

• Lubricants (1% CMC,1 hourly) • Scraping & culture was done which came out to be
• Homatropine 2% e/d tds negative.
• Oral doxycycline (100mg BD).
• Symptoms were relieved within 10 days with • Diclofenac e/d were stopped
• RE was put on antibiotics (moxifloxacin 0.5%), vigorous
decrease in size of epithelial defect, with few
infiltrates and superficial corneal vascularization. lubricants and atropine e/d along with anti-glaucoma
• Vision did not improve much due to central medication.
corneal scarring and final vision was 4 mts finger • After one month, condition improved.
counting. • But central corneal thinning still persisted.
• Patient was advised optical penetrating keratoplasty • Glue + BCL was applied for the same.
(PK) for the same eye. • Patient got symptomatic relief.
Patient#3
Patient#2 • Underwent bilateral phacoemulsification with
• Patient had history of glaucoma surgery(trabeculectomy) intraocular lens (IOL) implantation in 2006. Surgery
was uneventful.
in right eye (RE) 6 months back.
• H/o using diclofenec e/d since 2 months in RE 5 times • Patient had vision of 6/9 in both eyes (BE).

a day (t/d) for pain. • C/o DOV, pain and watering in LE since last 15 days.
• Complaints of foreign body (FB) sensation, pain and
• Give history of using ketorolac e/d and flurbiprofen e/d
redness RE since 20 days. in left eye 6t/d since one month after showing to an
• Vision fingre count close to face in RE ophthalmologist elsewhere.
• Conjunctival congestion, large epithelial defect, 20%
• But condition worsened for which he came back for
to 30% of central stromal thinning was present.

74 l DOS Times - Vol. 19, No. 4 October, 2013

Monthly Meeting Corner

Figure 7: Patient showing central macular Figure 8: Cornea: Central epithelial defect with
grade opacity (Patient 3) surrounding SPK’s was seen in both eyes (Patient 4)

Table 2: Ophthalmic NSAID’S

treatment to our institute. Figure 9: (Patient 4)
• RE was within normal limit (WNL) with vision of 6/9
• Treatment was given for another 3 weeks and patient
and in left eye it dropped down to finger counting 3 got symptomatically better.
meteres.
• Lids - normal • At 1month follow-up a central macular grade corneal
• Conjunctiva - congestion was seen. scaring was seen.
• Cornea - Decreased sensation, large epithelial
defect(6x5mm), underlying anterior-mid stromal • Vision was 6/60 in LE for which optical penterating
infiltration. keratoplasty (PK) was advised.
• NSAID’s were stopped.
• Patient was started on topical antibiotics (moxifloxacin Patient#4
6t/d) and vigorous lubricants (1% CMC, 12 t/d) for a • Young patient, came with complaints of watering and
week.
redness in BE since 15 days followed by DOV from
past 1 week.
• Patient was diagnosed as allergic conjunctivitis & was
started on flurbiprofen 0.03% e/d 6 times a day.

• Vision was 6/36 in BE.

www. dosonline.org l 75

Monthly Meeting Corner

• Lid swelling was seen • Nepafenac 0.1% significantly inhibits vitreous humor
prostaglandin formation that can reduce CME3,4.
• Conjunctiva: Congestion
Patients who need to be monitored
• Cornea: Central epithelial defect with surrounding
superficial punctate keratopathy (SPK) was seen in both • Dry eye
eyes.
• Diabetic
• NSAID’s e/d were stopped and was started on
olopatadine e/d once a day and lubricants at frequent • Previous surgery
intervals.
• Multiple eye drops
• Patient showed improvement after 2 weeks with vision
improving to 6/6. • HSV keratitis

Some facts about NSAIDS • Epithelial defects

• In the early 19th century, the nonsteroidal anti- Conclusion
inflammatory drug class was first used.
• NSAID’s these days are advertised more and more by
• It was during the last two decades, topical ophthalmic pharmacological companies leading to its unnecessary
NSAIDs have been used to control post-surgical pain usage in many patients.
and inflammation (Table 2).
• Although topical NSAIDs are easily available and
Side effects of NSAID’s2 used for a variety of nonspecific eye disorders, their
• Systemic effects of topical NSAIDs are very rare & excessive use can cause serious corneal complications.

mostly related to drainage from the eye through the References
nasal-lacrimal duct.
1. Flach AJ. Cyclo-oxygenase inhibitors in ophthalmology. Surv.
• Common side effect: Burning, stinging and conjunctival Ophthalmol. 1992;36:259-84.
hyperemia.
2. Wilson FM. Adverse external ocular effects of topical ophthalmic
• Severe effects include keratitis, corneal infiltrates and therapy: An epidemiologic, laboratory, and clinical study. Trans Am
corneal melts. Ophthalmol. Soc. 1983;81:854-965.

• Studies on diclofenac show an increase incidence of 3. Kapin MA, Yanni JM, Brady MT, et al. Inflammation-mediated retinal
corneal stromal ulceration. edema in the rabbit is inhibited by topical nepafenac. Inflammation.
2003;27:5:281-291

4. Heaton J, Hiddeman JW, Hackett RB, et al. Ocular effects of
nepafenac ophthalmic suspension following six months of topical
ocular administration to pigmented rabbits. Paper presented at: The
ARVO Annual Meeting; May 3, 2005; Fort Lauderdale, FL.

Announcement DOS Library

8 international indexed journals subscribed by Delhi Ophthalmological Society Library are
now available on line at DOS library; link on DOS website- dosonline.org

 Acta Ophthalmologica
  British Journal of Ophthalmology
   Cornea
    Current opinion in Ophthalmology
     International Ophthalmology clinics
      Journal of Glaucoma
       Journal of Neuro-Ophthalmology
        Retina

Any DOS member can directly access them with his DOS website login id and password

Prof. J.S. Titiyal Dr. Rajesh Sinha Dr. Vipul Nayar
President Secretary Library Officer

76 l DOS Times - Vol. 19, No. 4 October, 2013

DOS Times Quiz Delhi
Ophthalmological
Society

Instructions:

1. Please return your answers to [email protected] or mail them to “The Quizmaster, DOS Times Quiz, Dr. Rajesh Sinha,
Room No. 479, Dr. R.P. Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, Ansari Nagar, New Delhi -
110029”. Please write your DOS membership number along with your answers.

2. The answers should reach not later than 20th November, 2013.
The quiz can also be viewed and directly answered on our website www.dosonline.org
3. The results will be announced at the DOS monthly clinical meeting on 24th November 2013. The correct entry will be given a

prize of Rs, 2,500. If there are more than one correct entries, the winner of the prize will be decided by draw of lots.
Quiz compiled by Dr. Digvijay Singh

Quiz Prizes Sponsored by

M/s. Syntho Pharmaceuticals Ltd.

Ocular Surface Chronicles

Instructions:

This quiz scratches the surface of answer to What is the Ocular Surface?

Fill in the blanks below to reveal words related in some way to the ocular surface.

A. Harry Potter and the _________ of fire? The missing word C. The first half of my name rhymes with a metric number.
identifies cells that secrete me. What am I? The second half is something that should always
ui broaden for the better.

eo oe

B. The first half of my name is derived from a NATO phonetic D. I described a scoring scheme for rose Bengal staining
alphabet. The second half of my name rhymes with more. for xerophthalmia.
a ao
ai ee

Answer for September issue of DOS Times

(a) b e s t dy s t r op hy
ube l la
(b) c o n g e n i t a l r
r e t i nopa t h y

(c) C y t o m e g a l o v i r u s
ret ini t is

(d) c e n t r a l r e t i na l

v e i n o c c l u s io n

# ###

Membership No. __________ Name : _______________________Mobile No. _____________Email: _________________

Answer to DOS Times Quiz October 2013 B. _____________________________w_w__w_. _do_s_on_li_n_e._or_g_l_81
A. __________________________________________ D. ___________________________________________
C. __________________________________________

Tearsheet

Ocular Surface Disease Management

Treatment Algorithm in the management of ocular stem cell failure

A B

Procedure Abbreviation Donor Transplanted
tissue
Conservative Conjunctival transplantation Fellow eye
Conjunctival autograft Living relative Conjunctiva
Increased Non healing Recurrent Living-related conjuctival allograft CAU Conjunctiva
lubrication epithelial defects erosions lr-CAL Fellow eye
Limbal transplantation Limbus/
Conjunctival limbal autograft CLAU Cadaveric whole Conjunctiva
globe Limbus/
Punctal Occlusions - Punctal - Anterior Stromal Cadaveric conjunctival limbal c- CLAL Living relative Conjunctiva
- Collagen plugs occlusions Puncture allograft lr- CLAL Limbus/
- Silicone plugs - Tarsorrhaphy - Superficial KLAL Cadaveric stored Conjunctiva
- Cyanoacylate - Botulinum Keratectomy Living-related conjuctival limbal tissue Limbus/ Cornea
- Punctal Cautery injection - PTK allograft Fellow eye
- Canaliculectomy - Conjuctival flap Living relative Ex-vivo expanded
Keratolimbal allograft limbal stem cells
Fellow eye
Ex vivo expanded limbal autograft EVELAU Limbus/
Stored human Conjunctiva
Living related ex-vivo expanded lr- EVELAL amniotic membrane Human amniotic
limbal allograft membrane

Simple limbal epithelial SLET
transplantation

Amniotic membrane AMT
transplantation

www. dosonline.org l 87

Tearsheet

Holland Mannis classification of Ocular Surface Disease based on number of lost stem cells and presence or absence
of conjunctival inflammation

Normal Conjunctiva Previously inflamed Inflammed Conjunctiva
(Stage a) Conjunctiva (Stage b) (Stage c)

Partial Stem Cell Iatrogenic, CIN, contact lens History of chemical/ Mild SJS, OCP, recent
Deficiency (Stage I) (Stage I a) thermal injury (Stage I b) chemical injury (Stage I c)

Total/ sub-total Stem Cell Aniridia, severe contact lens, History of severe chemical/ Severe SJS, OCP, recent
Deficiency (Stage II) iatrogenic (Stage II a) thermal injury (Stage II b) chemical injury (Stage II c)

Comparison of various techniques of autologous limbal transplantation for treatment of unilateral limbal stem cell
deficiency

Features SLET CLET CLAU
Stages Single Two Single
Gap between stages None 2 weeks None
Donor tissue size in mm (clock hours) 2 (<1) 2 (<1) 10-20 (3-6)

Need for donor conjunctiva No No Yes
Need for stem cell laboratory No Yes No
Need for human AM Yes Yes No
Location of transplant All over cornea All over cornea At the limbus

Time to epithelialisation 4-6 weeks 0 4-6 weeks
Repeatable from same donor eye Yes Yes No

Donor eye LSCD No No Yes

Long-term success Awaited 50-100% 77-100%

Complications in recipient eye None None None

Courtesy: Br. J. Ophthalmol. 2012;96:931-934

SLET: simple limbal epithelial transplantation CLET: cultivated limbal epithelial transplantation CLAU: Conjunctival limbal autograft

Sana Ilyas Tinwala MD

Sana Ilyas Tinwala MD
Rajendra Prasad Centre for Ophthalmic Sciences,
All India Institute of Medical Sciences, New Delhi

88 l DOS Times - Vol. 19, No. 4 October, 2013