journal of the college of ophthalmologists of sri … · 2019. 8. 22. · journal of the college of...

• THE ANATOMY OF THE SUPERFICIALTEMPORAL ARTERY; A CADAVERICSTUDY OF THE COURSE IN RELATIONTO THE MAIN CLINICAL SURFACELANDMARKS

• PUPIL – SOME INTERESTINGASPECTS

• A PRELIMINARY MORPHOMETRICSTUDY OF THE HUMAN BONYORBIT

JOURNAL OFTHE COLLEGE OFOPHTHALMOLOGISTSOF SRI LANKAVOLUME 20 No. 1 2014

College of Ophthalmologists of Sri Lanka Annual ISSN 2345-9115

EditorsDr. Mangala Gamage, DO, MS, FRCS

Consultant Eye Surgeon,National Eye Hospital,Colombo 10, Sri Lanka.

Dr. Pradeepa K Siriwardena, DO, MS, FRCS

Consultant Eye Surgeon,Base Hospital, Horana,Sri Lanka.

Published byCollege of Ophthalmologists of Sri LankaNational Eye Hospital, Colombo 10,Sri Lanka.

Email: [email protected]@isplanka.lk

Telephone: 94+11-2693924Fax: 94+11-2693924Website: www.cosl.lk

Printed byAnanda Press82/5, Sir Ratnajothi Saravanamuttu Mawatha,Colombo 13, Sri Lanka.Tel: +94 11 2435975E-mail: [email protected]

Journal ofJournal ofJournal ofJournal ofJournal ofThe College of OphthalmologistsThe College of OphthalmologistsThe College of OphthalmologistsThe College of OphthalmologistsThe College of Ophthalmologists

of Sri Lankaof Sri Lankaof Sri Lankaof Sri Lankaof Sri Lanka

Journal of the College of Ophthalmologists of SriLanka is published annually in two volumes. It isclinically oriented, designed to keep ophthal-mologists up to date. It contains peer reviewedarticles, current research, case presentations andclinical challenges.

9 7 7 2 3 4 5 9 1 1 0 0 6

The College of Ophthalmologists of Sri Lanka publishesoriginal articles in Ophthalmology, original work onOphthalmology and related Sciences presented at meeting,congresses of the College as well as lectures, seminarsand symposia associated with the College. Articles subjectto editorial revision, may not be reproduced withoutpermission after publication. Statements in the articlesare the sole responsibility of the authors and not reflectthe opinion or attitude of the College or the editors.

Manuscripts typed in double spacing on one side of thepaper with 2” margin on both sides (three copies of themanuscripts and the CD) should be sent to the editorimmediately after the Annual Congress in order that theycould be included in the Journal of the same year. Anyscientific paper or research paper related to ophthalmology,will be accepted for publication.

Title page should be typed on a separate sheet and shouldbear the names of authors, their present posts and theplace where the work was carried out. The title should bebrief and meaningful to facilitate indexing. If authorshipis limited to direct participants, all other contributors topatient care must be acknowledged. The usual plan, a shortsummary, introduction, materials and methods, results,discussion and bibliography should be followed, when-ever possible.

Wherever ethical clearance is needed, the obtaining ofclearance must be acknowledged in the text.

Only standard abbreviations and SI units should be usedin the text. Drugs should be designated by their genericnames.

Illustrations such as graphs, charts and drawings shouldbe black ink on white paper or prepared using a computerand printed on a laser printer, and cited in the text. Legendsshould be typed on a separate sheet.

Photographs, x-rays, photomicrographs must be suppliedas glossy prints or in CD’s and magnifications indicated.Legends and captions should be typed on a separate sheet.Expenses for colour illustrations must be borne by authors.

Tables should have a title, numbered consecutively, typedin double spacing and submitted in separate sheet andcited in the text.

References should be double-spaced, arranged alphabeti-cally, by author, and cited by superior numbers in the text.Reference must be to primary publications, not to cita-tions of the articles in other publications.

Please provide complete publication data. Including firstand last page numbers. “in press” articles may be included;the journal must be specified. Presentations and manuscripts“submitted for publication” are considered unpublishedcommunication and, should be acknowledged in the text orfootnotes, but should not be listed with publishedreferences. Published abstracts may be included but shouldbe labeled “abstract”. Use Index Medicus style ofabbreviation, and punctuation. Some typical examplesfollow: note the absence of periods after initials andabbreviations. When there are 5 or more authors, name thefirst three, “et al” .

Journal Articles

1. Smith JD. Ophthalmology and the medical community.Surv Ophthalmol 41: 1-30, 1996.

2. Smith JD, Jones TS. Ophthalmology and society. SurvOphthalmol 42: 65-78, 1997.

Books3. Smith JD, Jones TS. Public JQ, et al: Ophthalmology

and the World. Boston. Bayside Press, 1997, pp 1-9.

Chapters4. Stevens JT. A transcendentalist’s view of optics, in Smith

JD (ed): Ophthalmology and the Universe, Vol. 6. Part 3.Boston, Bayside Press, 1997. ed 2, pp 230-245.

Proofs will be submitted to the first named author to bereturned within 4 days. No major alterations could be ac-cepted at this stage. Requests for reprints must be madedirect to the printer and paid for by the author. No freereprints will be supplied.

Instructions to Contributors

JOURNAL OF THE COLLEGE OF OPHTHALMOLOGISTS OF SRI LANKA

JOURNAL OF THE COLLEGE OF OPHTHALMOLOGISTS

OF SRI LANKA

VOL. 20 2014 NO. 1

CONTENTS Page

1 EditorialTeam work in eye careM. Gamage 1

2. Presidential Address 2013Ethical and moral aspects of patient careD. R. R. Kodikara 2

3. Idiopathic tuxtafoveolar telangiectasia (IJFT) in spectral domain opticalcoherence tomography (SdOCT)J. G. Mahesh, K. K. T. Sanjeewa, K. H. Wickramasinghe, D. Wariyapola 14

4. The anatomy of the superficial temporal artery; a cadaveric study of the course in relation to the main clinical surface landmarksA. K. G. Withana, W. S. Weerasinghe, K. A. Salvin 22

5. Dr. P. Sivasubramaniam OrationTraining – How did we get here and where are we going?K. Puvana Chandra 24

6. A preliminary morphometric study of the human bonyorbitA. K. G. Withana, W. S. Weerasinghe, K. A. Salvin 28

7. Pupil – some interesting aspectsK. Puvana Chandra 29

8. Current glaucoma surgeryDeven Tuli 32

9. Evaluation of the successfulness and complications of enucleation surgerywith acrylic orbital implant covered with human scleraPradeepa Bandara, Eranga Jayasinghe, Sadana Ekanayake, N. Kaleivarden,Tissa Senarathne, Saman Senanayake 36

10. Disc haemorrhage and the progression of glaucoma – an experienceC. Kumarage, K. H. Wickramasinghe, J. G. Mahesh, D. H. H. Wariyapola 40

11. Fellowship Awards 41

12. Cutaneous leishmaniasis, a differential diagnosis for eyelid lesionsM. R. C. K. Bandara, M. Gamage, S. Nanayakkara 43

13. A rare vitreo retinal dystrophy – juvenile retinoschisisJ. G. Mahesh, N. Attapattu, K. H. Wickramasinghe, D. H. H. Wariyapola 45

College of Ophthalmologists of Sri Lanka Annual ISSN 2345-9115

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Ethical and moral aspects of patient care

Team work in eye careThe Journal of the College of Ophthalmologists of Sri Lanka 2014; 20: 1

Eye care delivery was mainly the responsibility of the ophthalmologist in the past. It became clear thatin order to implement the work efficiently other types of health care personnel has to be developed.

The human resource development has been identified as essential building blocks in the WHO globalaction plan towards universal eye health.

In most of the regional bodies eye care development plan has been important part of advocacy plans.The composition of team varies from country to country and region to region.

Leadership

This is the most crucial of the team work. The leader should be knowledgeable, skilled, highly motivated,and who is aiming for sustainable eye care services. A good leader will always discuss with the teammembers and create a vision and goals that are shared by all.

What are qualities of a good leader,He or she will champion the teams vision with enthusiasm and encourage the team members to keepgoing during difficult times, will share the credits, ably manage negative fall outs.

The team leader is responsible for maintaining the team values, and culture.

Should module the correct attitudes and behaviour. Decision making is on evidence based approachrather than personal gains.

Members

The team members should be able to support the leader in achieving high performance and quality ofservice. They must be professionally competent in their field of work.

Task shifting

This has been used with lot of success to enhancing quality and quantity of work. Teams in health caremay face many additional challenges including financing and many health system issues.

We should do our best to provide great service and positive experience to our patients.

Team work can help by enhancing the efficiency and quality of our work, both of which are essential toimprove vision and quality of life of our patients.

Dr. Mangala GamageEditor

Editorial

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The Journal of the College of Ophthalmologists of Sri Lanka

Ethical and moral aspects of patient careD. R. R. Kodikara

The Journal of the College of Ophthalmologists of Sri Lanka 2014; 20: 2-13

At the very outset of this important event, I wish to remember and express my humble gratitude to my parents,grandparents, to all my teachers at St Sylvester’s College, Kandy and the Faculty of Medicine, University ofPeradeniya, to all consultant trainers who guided me in my postgraduate training, my relations and friends whogenuinely supported me in my long journey. I thank God, for, by his grace I am what I am today.

President, College of Ophthalmologists of Sri Lanka, 2013.

Presidential Address 2013

Tribute to....

• Dr. Upali Mendis• Dr. Mrs. C. D. Jayaweera Bandara• Dr. K. Puwanachandra• Dr. Mrs. Champa Banagala• Dr. C. A. B. Makuloluwa• Dr. Saliya Pathirana• Dr. Charith Fonseka

I have selected a topic for tonight which has always been close to my heart.

That is improving the quality of care in the practice of modern ophthalmology without losing sight of the patientcentered approach, which is nothing but “the ethical and moral aspects of patient care”.

Several pertinent questions intimately related to this topic are:

Have I managed my patient to the best of my ability?

Have I, at all stages of providing care and therapy, maintained the safety of my patient and his or her eye sight asmy prime concern?

Have I given due consideration to the expectations of my patient when making decisions?

Is my practice and my conduct ethical in the eyes of my colleagues and my patients?

It is to emphasize that how can I provide the best care to my patient?

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Therefore, it is the good doctor-patient relationship that I wish to highlight in my address, not from the physician’sperspective but from the patient’s perspective.

It is good to remember that one day each one of us may have to wear the patient’s shoes.

In our busy practice with heavy clinics and long theater hours we may develop a different set of attitudes over aperiod of time. At extreme cases we sometimes hear strange stories about medical personnel who demonstratenomoral values.

The best way of understanding this approach is the approach of good medical practice or the patient centeredapproach, if you consider that you are a patient then what would you like your doctor do for you?

I want to introduce this subject with two real life incidents.

One day a friend of mine went with his wife to meet a senior surgeon for a consultation. Subsequently a biopsyrevealed the presence of cancer.

The way that surgeon shared the news, caused much distress to my friend.

When I heard this I felt very sorry for them, and concerned that we as medical professionals are often insensitiveto the feelings of our patients and their relatives.

Another incident is where a patient had gone to a surgeon for a second opinion as the patient was not quitesatisfied with first surgeon’s overall approach. The comment of the second surgeon was so serious and critical.This made the patient go for a third opinion and soon after the consultation was over asked, “Sir, Why did theother doctor make such a comment about the first surgeon whom I went to see? I don’t know whether they areangry with each other”. It is sad to note that this was the perception created in the mind of the patient as a resultof this drama.

As doctors how do we analyze such situations? Even the most technologically advanced eye surgery is an art andcomplications do occur. We all have our strengths and weaknesses. However irrespective of how technicallycapable we are, the principles of total patient care and good medical practice remain the foundation of ourapproach and this is what patients expect from a good doctor.

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Rapid global advancement / Newer methods of communication / Ophthalmology and ophthalmic education

However we must remind ourselves that we are living in an era where there is a rapid global advancement intechnology on an unprecedented scale.

Newer methods of communication and connection have been invented, refined and expanded at a breathtakingpace. Worldwide these changes and advancements have had diverse implications and applications.

Such changes have a significant impact in the field of ophthalmology and ophthalmic education.

What remains unchanged, however, is regardless of where you practice, what level of education and training youhave received, all of us – the ophthalmologists strive; to provide the best possible eye care to our patients. Thismust be our motto.

Winston Churchill once remarked

“The longer you can look back the further you can look forward”

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Let me therefore give you a glimpse of the practice of ancient ophthalmology.

According to the writings of Herodotus, the great historian the Babylonians had no physicians; the patient wasbrought out to the market place and shown to all passersby to discover whether any of them had been afflictedwith the same disease or had seen others with a similar condition. The advice is sought from them how suchpatients found cure.

Ancient practice of ophthalmologyBabylonians had no physicians

The famous Code of Hammurabi written in 2250 BC during the Bronze age mentions rewards and penalties forphysicians. It is interesting to note that considerable number of sections of these laws relate to ophthalmology – orrather to ophthalmic negligence or malpractice.

Rewards and penalties for physicians

Code of Hammurabi (2250 BC/Bronze age)

The Code enacts that for a successful operation which saves the eye of the patient the fee shall be ten shekels in thecase of a “gentleman”; the nobleman of that era but only five shekels and two shekels in the case of a poor man andfor a slave respectively.

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For an unsuccessful operation if the outcome is death or the loss of the eye, the surgeon shall have his hands cutoff; in the case of a slave the penalty was for the surgeon to provide another slave to the master.

• In these age ancient Egypt all learning of the times was imparted in the temple school and so, priests weredoctors and doctors’ priests.

• In 460 BC, in the Golden age of Greece, Hippocrates, The father of medicine completed the separation ofscientific medicine from temple practice and magic.

• He taught that “The physician is a servant, not a teacher of nature” – do enough but never too much.

Hippocrates 460 BCSushruta

• Treating cataracts can be traced back to the fifth century BC in India. A Hindu surgeon called Sushruta inhis Encyclopedia, he has recorded a chapter about couching. This was a surgery to push the lens out of thevisual field, so that the cloudiness of its cataract did not impair vision. A needle was used, or a hard blowto the eye or head. This practice had been in the past even in Sri Lanka.

• Galan, (AD131-201). This Roman master of medicine has been called the greatest of all physicians, addeda wealth of knowledge to the ophthalmology.

• He declared nature created nothing defective and nothing in vain. He describes the eye as the most divineof the organs and admires the wisdom of the creator who took such care of brain and retina.

Further advance in ophthalmology was made possible by the study of anatomy of the eye, and by an understandingof the mechanism of vision. This was the work of the 16th and 17th centuries and paved the way for the greatpathological and clinical progress of the 18th century, the century of the cataract extraction. The first half of the19th century was a remarkable period of consolidation, and the second half brought the operative treatment ofGlaucoma, and the ophthalmoscope opened a world undreamt of and raised ophthalmology to the most exact ofclinical studies.

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For us to understand where we stand now due to the technological revolution, I would like to show you some keytechnical advances in the recent past.

Technical advances1. Cataract surgery technique2. Equipments to increase accuracy3. New glaucoma shunts4. Advances in ocular imaging5. Implants for macular degeneration6. Electronic medical recording (EMR) systems for ophthalmology practices7. Advanced laser systems, Femtosecond LASER for cataract surgery8. Premium IOL

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Nano technology

• The world has just begun to enter into an unknown territory of Nano technology leading to Nano medicine,Which is the concept of things at the small scale. In 1990, thanks to the invention of atomic force microscope,it was shown that the individual atoms can be manipulated so that they begin to exhibit different characteristics.

• This technology is tested in the treatment of oxidative stress, choroidal new vessels and retinal degeneration.It is also being researched and tried in preventing scarring in glaucoma surgery and drug delivery systems inthe eye. Intravitreal steroid implants made using the same technology was launched recently in Sri Lanka.

Applications

• Treatment of oxidative stress

• Choroidal new vessels

• Retinal degeneration

• Prevent scarring in glaucoma

• Surgery

• Drug delivery

So far, what I have tried is to show you how fast we are developing technologically and where we are heading for?

• At this stage, may I pause a crucial question? With the pace of this technological advancement, is ourethical and moral aspects of patient care improved? Which is a major part of total patient care.

• As we are in the 21st century with very high expectations on the patients end, we are compelled to providethe highest possible quality of care in ophthalmology.

Quality of care

• In the context of health care, what does it mean? – doing the right thing, at the right time, for the rightreasons to obtain the best achievable health outcomes.

• Quality health care should be appropriate, accessible, effective, safe and provided by someone who iscompetent and accountable for practice.

• The twin challenges in health care are delivering a higher quality of care much more efficiently.

• In the developed world there is a ‘quality chasm’ between the quality of care that can be achieved andquality and consistency of care that is being delivered.

• Mahatma Gandi once said

• “Live as if you were to die tomorrow. Learn as if you were to live forever.”

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• “In a time of drastic change it is the learners who inherit the future. The learned usually find themselvesequipped to live in a world that no longer exists”.

• Therefore we have to continue our professional development.

• Continuous professional development (CPD) is defined as the systematic maintenance and improvementof knowledge, skills and competence, the development of personnel qualities necessary for professionalduties and enhancement of learning, undertaken by an individual throughout his or her working life.

• The purpose of CPD is to enhance the quality of patient care.

The college has started the CPD program few years back but we need some dedicated surgeons to carry it forwardin organizing CPD programs and assessing either through input based or output based systems

• This is one area the college has to focus in the coming years to improve the quality of ophthalmic care inthis country.

• As part of the quality of care, we attempt to practice Evidence based medicine.

• The practice of EBM means integrating individual clinical expertise with the best available externalclinical evidence from systematic research. However when we apply this concept to an individual patient,it is very important to differentiate between.

• A. What is statistically significant

• B. What is clinically significant

But more importantly

• What is significant for the safety of our patient?

• The concepts, techniques of surgery and management strategies are changing very rapidly.

During my time of training the technique of cataract surgery was changed from intracapsular to extra capsularand then to Phacoemulsification within a space of three to four years.

The trainees and young surgeons in ophthalmology should be aware of this rapid change of practice and theyshould be mentally prepared for that task to grasp the new trends.

Upgrading surgical skillsIn continuous medical education, it is important for us to continually upgrade surgical skills.

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How do we perceive the need to train doctors for the future using models as patients in the 21st century?

This is an issue which has not been raised in the past. However present situation is different.

Ethical issues and litigation problems can arise during the training period.

Therefore it is better to look into alternative methods to improve surgical skills. The whole idea is to minimize thesurgical complications during the training period and also for experienced surgeon when he or she attempts tolearn a new technique;

The suggestions would be

To use simulators in surgical training

• Setting up of Wet lab facilities in the tertiary centers, we have already planned to set up a Wet Lab at theNational Eye Hospital Colombo and it will be operational in the near future.

• Effects of clinical guidelines in giving best quality of care.

• In the past doctors practiced usually on their individual opinions and experience. If a senior colleaguehad recommended something, it was very rarely challenged by the juniors. Gone are these days.

• At present we can’t deviate from the standard practice. We have to abide by the clinical guidelinesremembering that they are guidelines and not rules.

• Clinical guidelines are defined as “systematically developed statements to assist practitioner decisionsabout appropriate health care for specific clinical circumstances.”

• The college has initiated developing guidelines many years back. There should be new guidelines and theold guidelines should be revised regularly.

• Good doctors, safer patient’s axiom suggests that many of the problems of poor delivery of ophthalmiccare are attributed to unsafe systems.

• We know that the majority of doctors are committed to delivering high quality and safe health care, yet anumber of patients continue to suffer from avoidable errors and system failures.

WHO definition

• Health is a state of complete physical, mental and social well-being (three dimensions) and not merely theabsence of disease or infirmity. /

• Material progress in the present world has reached levels unprecedented in past history or civilization.Yet we find that what prevails in this world are anxiety and apprehension, we have stripped man, overthe last decades, of his spiritual values and materialism is now in full control of all aspects of our life.Regardless of what we do to provide health care for the body and mind, man shall remain lost and restlessuntil we provide for the spiritual aspect of life.

• The vision of the Ministry of Health in Sri Lanka – a healthier nation that contributes to its economic,social, mental and spiritual development.

Sri Lanka Medical Council – Code of Ethics

Sri Lanka Medical Council has its own Guidelines on Ethical conduct for medical and dental practitionersregistered with the SLMC. It starts with this verse “Medicine is a sacred calling and he who makes it ridiculous isguilty of sacrilege” – Sodhoff.

Medicine is ranked among the noblest of professions. Hence, service to humanity and not personal gain is theideal of the profession and one who chooses to join the profession must assume the obligation to conduct himselfin accordance with the ideal.

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• Various bodies and colleges have their own standard of care and ethics according to the country’s background.

• Ethics is the systematic study of what is right and good with respect to conduct and character. Ethicsseeks to answer two fundamental questions:

1) Should we do? 2) Should we do it?

• As an intellectual discipline, Ethics is concerned not only with making appropriate decisions about whatwe ought to do, but with justifying those decisions.

To ask what a physician should do in a particular case is to ask an ethical question, and to justify our answer weappeal to the same rules and principles that apply to persons in society generally.

Teaching and practice of ethics

• One of the ways in which professionals have traditionally governed their behavior is through a code ofethics. A code of ethics is a statement of general principles of duty to which the members of the professioncommit themselves, and through which the profession is given its moral character.

• The most familiar code of ethics in medicine is the oath of ethics of Hippocrates.

• Modern codes of medical ethics have a direct debt of gratitude to the Hippocratic principle.

• For example, one of the principles of the American Academy of Ophthalmology Code of Ethics states that“It is the responsibility of an ophthalmologist to act in the best interest of the patient” a commitment thatAcademy has described as the code’s “exclusive goal.”

The American Academy of Ophthalmology (AAO) is dedicated to providing ophthalmologists with informationand education necessary for the optimal ophthalmic care of the public in states.

• The Academy’s Code of ethics, which serves as standard of exemplary professional conduct, requires thatan ophthalmologist be competent by virtue of specific training and experience.

• Physician competence exists for the purpose of advancing the best interests of the patient as a person withsensitivity and with respect for and understanding of their sovereignty, needs and wants.

• Medicine is a moral practice, because physicians are concerned primarily with advancing the interest ofpatients and doing for patients what they wish to have done for themselves. Unlike members of otherkinds of practices, the physician places the interest of others above her or his own interests.

Indeed, this feature of medicine is one of the defining characteristics of health care profession in general.

• Competent ophthalmologic practice requires both technical and moral capacities.

• Technical capacities are comprised of the knowledge and skills required to practice ophthalmology,according to current standard of care.

• Moral capacities are demonstrated by

1) Acting as an agent of the patient.

2) Developing a caring relationship with patients.

3) An appreciation of clinical ethical problems.

It is a continuing process of self-development of acquiring and refining the knowledge, skills, values andexpectations to provide quality patient care.

• Moral competence follows from understanding the purpose of medical care and calls upon the physicianto practice moral discernment, moral agency, and caring in relationship.

• Moral discernmentis the ability to recognize, confront discuss and resolve the ethical consideration in aclinical encounter.

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In particular, it is the ability to: Respect the cultural, social, personal beliefs, expectations and values thatthe patient brings to the therapeutic setting.

• Moral agency is the ability to act on behalf of the patient; to act with respect for social. religious andcultural differences that may exist between physician and patient.

• A caring and healing relationship between physician and patient is the foundation of medical care.

Technical competence

• Technical competence consists of knowledge and skills necessary to diagnose and treat disease anddisability according to the precepts of medical science and especially of ophthalmology, and to assist inthe maintenance of health. Technical competence is a comprehensive construct.

The AAO acknowledge the importance of these moral commitments and technical capacities to the education,practice and credentialing ophthalmologists. Further, the curriculum of ophthalmology should specifically addresseach of these competencies and the two paths to developing them and should be defined further for purposes ofassessment and accountability.

According to the medical ethics guidelines given by the Sri Lanka Medical Council.

• Whatever the provocation may be, they should act with restraint and abstain from rude or abusive behaviorto patients, colleagues and other staff.

• Practitioners are advised to show sympathy and compassion to patients at all time.

• Professional misconduct could be caused by depreciation by one doctor of the skill, knowledge,qualification or services of another doctor. It is the responsibility of a practitioner to bring instances ofprofessional misconduct, medical incompetence, incapacity, dishonesty or negligence of a fellow medicalpractitioner to the notice of the Medical Council in the best interest of the medical profession and thegeneral public.

• Are we teaching ethics and its value to our undergraduate and postgraduate students?

• Medical ethics, in Sri Lankan medical schools, is traditionally taught by the members of the departmentsof forensic medicine. However of late it has been given much importance.

• Are we guiding and assessing our younger generation in standard ethical and moral aspects of ophthalmicpractice?

• In Sri Lanka, there is a huge vacuum in teaching and inassessing the moral and ethical qualities of adoctor in the undergraduate as well as in the postgraduate level of education.

• This is reflected in some doctors‘ modern day practice of ophthalmology once they are qualified.

• Are we giving total patient care?

One important fact is that we are unable find adequate role models in this subject.

• Good doctors make the care of their patients their first concern: they are competent, keep their knowledgeand skills up to date establish and maintain good relationship with patients and colleagues, honest andtrustworthy, and act with integrity.

• Healthcare quality and patient safety is a topic which attracted global attention currently. The WHO hasidentified healthcare quality and patient safety as priority areas of concern.

• Thanks to some of our members, an ethical review committee for the purpose of approving the researchprojects was established recently at the Eye Hospital. Will this be the beginning of the formulation of acode of ethics for our members?

• As we are now fast approaching the need for a code of ethics in ophthalmology in Sri Lanka.

• Which will protect our members on one hand and on the other, will ensure a good doctor – patientrelationship.

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• Medical ethics, itself is a vast subject and it is beyond the scope of my address. But I hope that this will bean eye opener to everybody as medical professionals.

• Let me end with this quote from Hippocrates:

• “Wherever the art of medicine is loved, there is also a love of Humanity.”

I would like to thank the council members of the College of Ophthalmologists of Sri Lanka and the association ofvitreo retina specialists in Sri Lanka, specially Dr. Saliya Pathirana, the Present President of the Association andDr. Charith Fonseka, the Founder President of the Association for their willingness and co-operation to have ajoint meeting this year.

I also take this opportunity to thank the Director and the Deputy Directors, colleagues, my staff including doctors,nurses and others at Colombo South Teaching Hospital for their continuing support.

I thank Mrs. Roxana, Mr. Nuwan and Mr. Gershaun for the assistance given in preparing the address. Specialthanks to my friends Prof. Mohan Silva and Dr. Arulanketell for their guidance. Last not least I thank my wifeRanjini and Son Theekshana for their patient and support without which I couldn’t have done any of these.

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Idiopathic tuxtafoveolar telangiectasia (IJFT) in spectral domain opticalcoherence tomography (SdOCT)J. G. Mahesh1, K. K. T. Sanjeewa2, K. H. Wickramasinghe3, D. Wariyapola4


Introduction

Idiopathic juxtafoveolar retinal telangiectasis (IJFT), also known as parafoveal telangiectasis or idiopathic maculartelangiectasia, refers to a heterogeneous group of well-recognized clinical entities characterized by telangiectaticalterations of the juxtafoveolar capillary network of one or both eyes and variable intraretinal exudation.Incompetence, ectasia, and/or irregular dilations of the capillary network affecting only the juxtafoveolar regionof one or both eyes differentiate it from other retinal telangiectasias. IJFT was first described and classified by Gassand Oyakawa in 1982. In 1993 Gass and Blodi further updated this classification based on demographic differenceor clinical severity and angiographic findings. More recently, based on newly recognized clinical, angiographic,and optical coherence tomography (OCT) imaging observations, Yannuzzi et al. proposed a revision andsimplification of the Gass-Blodi model. Despite of the complexity, Gass and Blodi classification is the mostcommonly used to date.

Group I:

Visible and exudative idiopathic juxtafoveolar retinal telangiectasis

Also called idiopathic macular telangiectasia Type 1 or aneurysmal telangiectasia, a congenital entity occurringpredominantly in males (>90%) and is unilateral in >90% of cases.

Biomicroscopic features includes, a consistent hallmark of prominent easily visible telangiectatic retinal capillarieswith variable-sized aneurysmal dilatations. Telangiectasis usually involves a two-disc diameter area or greatertemporal to the fovea. Macular edema and lipid deposition of variable amount is a characteristic feature. Visualloss is due to macular edema.

On angiography, IJFT group 1 is characterized by easily visible telangiectatic vessels and aneurysmal capillarydilatations straddling the horizontal raphe and prompt filling in both the superficial and deep juxtafoveolarcapillary plexus. Minimal nonperfusion or capillary ischemia exists sometimes and is easily visible on FA.Central cystic or noncystic macular edema is evident angiographically as late intraretinal staining.

IJFT – group 1 is characterized by SdOCT findings of increased central retinal thickness and intra-retinal fluidfilled spaces. In some eyes, the edema extends beneath the retina to produce shallow detachments of the maculavisible only with OCT. On ultra-high resolution OCT (UHR-OCT), characteristic abnormally large intraretinalblood vessels located near the fovea and deep in the outer nuclear layer can be visualized.

1Senior Registrar in Ophthalmology, Sri Jayewardenepura General Hospital, 2Senior Registrar in Ophthalmology,National Eye Hospital, 3Medical Officer, Sri Jayewardenepura General Hospital, 4Consultant Ophthalmologist,Sri Jayewardenepura General Hospital, Sri Lanka.

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Idiopathic tuxtafoveolar telangiectasia in spectral domain optical coherence tomography

Group II:

Occult and nonexudative idiopathic juxtafoveolar retinal telengiectasis

Is also called idiopathic macular telangiectasia Type 2 or perifoveal telangiectasia which is the most commontype of IJFT. The entity is acquired and bilateral occurring in both middle-aged men and women. Telangiectasismore difficult to detect on biomicroscopy, but with characteristic and diagnostic angiographic and OCT features.Vision loss is due to retinal atrophy, not exudation. Subretinal neovascularization is common.

It is characterized biomicroscopically by loss of transparency of temporal parafoveolar retina without easilyvisible telangiectatic vessels or aneurysmal dilatations. There may be numerous superficial retinal refractilecrystals, dilated right angled vessels temporaly and intra-retinal pigmented epithelial plaques. Proliferative stageis featured by the onset of CNV.

Angiographically there is early discrete staining of temporal parafoveolar capillaries which increase in intensityin late phase. There are no clearly visible telangiectasis or aneurysmal dilatations. Proliferative stage showsfeatures of CNV.

Spectral domain OCT shows small inner lamellar retinal cysts ‘‘cystoid’’, intra retinal hyper-reflective areacorresponds to pigment epithelial plaques with posterior shadowing, absent macular oedema, foveal flatteningin late stages, disruption of IS/OS junction line and outer retinal atrophy.

Group II A – on biomicroscopy

Loss of transparency of temporal parafoveolar retinaNo easily visible telangiectaticvessels / aneurysmaldilatationsNumerous superficial retinal refractile crystalsDilated right angled vessels temporalyIntra‐retinal pigmented epithelial plaquesProliferative stage – onset of CNV

Group 1- OCT findingsIncreased central retinal thickness

Intra-retinal fluid filled spaces

In some eyes, the edema extends beneath the retina to produce shallow detachments of the macula visible only with OCT

On ultra-high resolution OCT (UHR-OCT), characteristic abnormally large intraretinal blood vessels located near the fovea and deep in the outer nuclear layer can be visualized

Group II A – on FFAEarly discrete staining of temporal parafoveolar capillaries

Increase in intensity in late phase

No clearly visible telangiectasis / aneurysmal dilatations

Proliferative stage – features of CNV

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G roup II A – OCT findingsSmall inner lamellar retinal cyst “cysto id”Intra retinal hype r-ref lective area corresponds to pigment epithelial plaques w ith posterior shadow ingAbsent macular oedemaFoveal flattening in late s tagesDisruption of IS/ OS junction lineOuter retina l atrophy

Group III:

IJFT group III is very rare, characterized predominantly by progressive obliteration of the perifoveal capillarynetwork, occurring usually in association with a medical or a neurological disease.

Objectives

1. To describe and classify IJFT based on SdOCT

2. To evaluate the usefulness of SdOCT in diagnostic dilemmas.

Material and methods

Prospective descriptional study conducted in Sri Jayewardenepura General Hospital over six months periodfrom 01/12/2012 to 31/05/2013. All patients suspected to have IJFT on dilated funduscopy (biomicroscopy)underwent colour fundal photography, fundal fluorescein angiography (FFA) and spectral domain OCT (SdOCT).Patients confirmed with IJFT were included in to the study. Group was determined according to the Gass andBlodi classification.

Results

22 eyes of 11 patients were studied, out of which 3 patients (27%) were males and 8 (73%) were females. Visualacuity span from 6/9 to 6/60, 36.4% were within 6/12 – 6/18 range and 40.9% within 6/24 – 6/36 range. In thiscase series bi-laterality was 100%.

17 eyes (77.3%) showed sub foveal intra-retinal cystoid spaces (foveal cysts) and 19 eyes (86.4%) had disruptedIS/OS junction on SdOCT. 17 eyes (77.3%) had outer retinal atrophy and 5 eyes showed intra-retinal pigmentepithelial plaques with posterior shadowing (22.7%). Both eyes of one of the patient (54 year old male) showedevidence of subfovealchoroidal neovascularization. All patients were confirmed as having Group IIa idiopathicjuxta foveal retinal telangiectasia.

Case 1: A 45 year old non-diabetic female present with poor vision in both eyes. Visual acuity OD: 6/36, OS: 6/18.Fundal appearance showed loss of transparency of temporal parafoveolar retina. There were no visible telangiectaticvessels or aneurysmal dilatations. Fluorescein angiography showed early discrete staining of temporal parafoveolarcapillaries which increase in intensity in late phase. There are were clearly visible telangiectasis or aneurysmaldilatations. SdOCT demonstrated intra-retinal cystoid spaces and disruption of IS/OS junction in both eyes.These findings were compatible with group II juxtafoveal retinal telangiectasia.

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Case 01:Mrs HCT: 45 y, OD: 6/36, OS: 6/18

Case 01:Mrs HCT – sd OCT

sd OCT - OD

sd OCT -OS

Case 2: 53 year old female with visual acuity of OD 6/12, OS 6/60. Fundus showed loss transparency in temporalperifoveal region in both eyes and pigment plaque in left eye. SdOCT showed retinal atrophy, intra retinal cystoidspaces, disruption of IS/OS junction in both eyes and hypereflective lesion with posterior shadowing correspondingto the intra-retinal pigment plaque in left eye.

Case 3: 55 year old female with visual acuity of OD 6/36, OS 6/24 who showed similar biomicroscopic andSdOCT findings.

y / , /

Case 2:Mrs. WAJF: 53 y, OD: 6/12, OS: 6/60

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Case 4: 52 year old male patient with visual acuity of OD 6/24 and OS 6/12 present with biomicroscopic andangiographic evidence of bilateral subfoveal choroidal neovascular membrane. SdOCT showed intra retinalcystoid spaces and disruption of IS/OS junction apart from evidence of CNV indicating that juxtafoveal retinaltelangiectasia is the most likely cause for CNV at relatively young age in this patients.

Case 5 to 11: Following illustrations show similar SdOCT features characteristic of juxtafoveal retinal telangiectasia.

Case 04:Mr. RK – 52 years, OD: 6/24, OS: 6/12

sd OCT - OD

sd OCT - OS

Case 3:Mrs. NMM: 55 y, OD: 6/36, OS: 6/24

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Case 06:Mrs. DP - 55 years OD: 6/36, OS: 6/36

Case 05:Mrs. GP: 50 yOD: 6/36, OS: 6/36

Case 07:Mrs. SR: 56 y –OD: 6/12, OS: 6/12

Case 08:Mr.HR: 52 y –OD: 6/60, OS: 6/9

Case 09:Mrs.IKR: 63 y –OD: 6/18, OS: 6/18

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Case 10 : Mr. NG – 56 y , OD: 6/60 , OS: 6/9

Case 11:Mrs. GWCP – 54 y, OD: 6/24, OS: 6/18

Discussion

There has been several studies published illustrating OCT features of idiopathic juxtafoveolar retinal telangiectasia.Following chart gives a comparison of such studies.

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It is clear that presence of intra-retinal foveal cysts, disruption of IS/OS junction, outer retinal atrophy andabsence of thickened fovealcentre are fairly uniform SdOCT findings of juxtafoveolar retinal telangiectasia. Intra-retinal hyper-reflective lesions with posterior shadowing due to pigment plaques are characterized in the advancedstages of the disease.

Conclusion

Spectral domain OCT is a useful tool in diagnosing and classifying idiopathic juxtafoveolar retinal telangiectasiaand in resolving diagnostic dilemmas.

References

1. Sawsan R. Nowilaty, et al. Idiopathic Juxtafoveol2ar Retinal Telangiectasis: A Current Review. Middle East African Journal ofOphthalmology 2010; 17(3): 224-41. doi: 10.4103/0974-9233.65501.

2. Gaudric A, Ducos de Lahitte G, et al. Optical coherence tomography in group 2A idiopathic juxtafoveolar retinal telangiectasis.Arch Ophthalmol 2006; 124(10): 1410-9. PMCID: PMC2934714.

3. Cohen SM, Cohen ML, et al. Optical coherence tomography findings in nonproliferative group 2A idiopathic juxtafoveal retinaltelangiectasis. Retina 2007; 27(1): 59-66.

4. Surguch V, Gamulescu MA, Gabel VP. Optical coherence tomography findings in idiopathic juxtafoveal retinal elangiectasis.Graefes Arch ClinExp Ophthalmol 2007; 245(6): 783-8. Epub 2006 Nov 22.

5. William T, Edward AJ. Duanne’s Ophthalmology, 2011 edition.

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The anatomy of the superficial temporal artery; a cadaveric study of thecourse in relation to the main clinical surface landmarksA. K. G. Withana1, W. S. Weerasinghe1, K. A. Salvin1


Introduction

The superficial temporal artery (STA) is the mainarterial supply to the scalp covering the temporal andfrontal regions. It is the main terminal branch of theexternal carotid artery having many musculo-fascialand cutaneous branches. The course is related to thetragus, zygomatic bone and the parotid gland.

The branches of clinical significance on - anterior -frontal branch, posterior - parietal branch, transversefacial, auricular, zygomatico-orbital, middle temporal,unnamed branches.

Anatomical studies of major divisions of the artery arespares in the local literature.

The clinical significance of STA is pronounced by thefollowing studies done todate. Temporal arteritis is animportant clinical condition that may lead to blindnessin the adult population. The main stay of diagnosis isby histopathological examination of biopsies obtainedfrom the temporal artery.2 Different reconstructivesurgeries are being done based on the anatomy of theSTA and muscular and skin flaps supplied by thevessel.3 The role of extracranial arteries in the patho-physiology of pain in migraine headache is a new fieldof interest where arterial diameter changes have beenstudied4.

Therefore, this study was designed to fulfill the needof understanding this important anatomical region ofclinical interest.

Objective

To describe the anatomy of the superficial temporalartery in relation to well established anatomicallandmarks of the face in a sub population of Sri Lankancadavers.

Methodology

Study design – A descriptive anatomical study.

Study setting – Department of Anatomy, Faculty ofMedicine, University of Kelaniya.

1Department of Anatomy, Faculty of Medicine, University of Kelaniya, Sri Lanka.

Sample size – 20 cadavers obtaining 40 specimensfor dissections.

Duration of the study – 3 months from April 2013.

Exclusion criteria – any gross facial defects detectedon cadavers.

Ethical clearance was obtained from the ERC, Facultyof Medicine, University of Kelaniya.

Results

The STA was present in all the specimens with itsparietal and frontal branches. Division into the mainbranches occurred at 2.45 ± 0.2 cm horizontally fromthe tragus (A) 2.67 ± 0.22 cm vertically from themaxillary process of the zygomatic bone (B). The courseof the main trunk of the STA was observed within theregion of lines vertically drawn from the tragus andhorizontally from the tragus to the lateral canthus.

Thirty two specimens demonstrated lesser branchesand one specimen had no transverse facial artery.Branches penetrating the skull were not described inthe study.

Dissection protocol

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The anatomy of the superficial temporal artery; a cadaveric study of the course in relation to the main clinical surfacelandmarks.

Figure 1. The site of division into main branches. Figure 2. Schema of major divisions.

Discussion

STA measurements can be used for location of thevessel in clinical procedures. Surface landmarks arehelpful in tracing the vessel course precisely. Divisionof the main trunk occurs at a point within rangescompatible with surface landmarks. Generalization offindings needs further studies with further extensionto include comparative clinico-anatomical study of theSTA.

References

1. Stranding Susan; Gray’s Anatomy, Eleventh Edition, Elsevier.

2. Haug SJ, Yoon MK, Porco T, Seiff SR, McCulley TJ. ANational Survey of Practice Patterns: Temporal ArteryBiopsy. Ophthalmology 2013; 25.pii:

3. Tenna S, Brunetti B, Aveta A, Poccia I, Persichetti P.Scalp reconstruction with superficial temporal artery islandflap: clinical experience on 30 consecutive cases. J PlastReconstr Aesthet Surg 2013; 66(5): 660-6.

4. Amin FM, Asghar MS, Hougaard A, Hansen AE, LarsenVA, de Koning PJ, Larsson HB, Olesen J, Ashina M.Magnetic resonance angiography of intracranial andextracranial arteries in patients with spontaneousmigraine without aura: a cross-sectional study. LancetNeurol 2013; 12(5): 454-61.

24


Training – How did we get here and where are we going?K. Puvana Chandra


Consultant Ophthalmologist, Department of Ophthalmology, Norfolk and Norwich University Hospital, Norwich, U.K.

It is indeed a great honour and privilege to be invitedby the College of Ophthalmologists of Sri Lanka todeliver the 2013 Dr. P. Sivasubramaniam oration.

It is of particular significance to me to honour a greatteacher in the presence of my own mentors whoseadvice and guidance have helped me in many ways.

I met Dr. P. Sivasubramaniam as a junior trainee duringthe monthly case presentations at the Colombo EyeHospital, which he attended very regularly eventhough he had left hospital eye service. Very soon hisimmense wisdom and extensive experience as well asthe interest he had on ongoing training of all concernedbecame very evident. What impressed me most washis readiness to interact with his colleagues and juniortrainees alike and the ability to inspire.

Training and transfer of skills was given the utmostimportance in all his academic and professionaldealings with fellow ophthalmologists and theeffort he took to establish the Sri Lankan College ofOphthalmologists is a testament to the devotion andcommitment Dr. Sivasubramaniam had for ourspeciality.

Despite a busy practice, conducting eye camps in theperiphery and other professional commitmentsDr. Sivasubramaniam made time to publish in peerreviewed journals like the British Journal of Ophthal-mology, organise and preside the fourth congress ofthe Asia Pacific Academy of Ophthalmology inColombo, thus helping to take Sri Lankan ophthal-mology to the international arena.

In keeping with your President’s suggestion and myown wish I like to devote this oration to ophthalmictraining, a favourite topic of Dr. Sivasubaramaniam.

Looking at the history of surgical training would helpus to understand how it developed over the years tomeet the ongoing advancements and the ever changingdemands.

There is evidence to suggest that training and transfer

of skills has been an integral part of human evolution.Anthropological studies show primates used andtrained their offspring in handling tools possibly beforehumans walked the surface of this planet. It is likelythat the transfer of skills was part of the evolutionaryprocess of humanoids and the tools as well as themethods of training in their use progressed with’’evolution’’ and played an important part in naturalselection. We are seeing great leaps in technology asnever seen before, leading to rapid changes both indiagnosis as well as the treatment of diseases.

Surgery in particular in the information age isundergoing dramatic changes due to introduction ofrevolutionary technology, at times rather abruptlyresulting in considerable disruption to treatmentpathways as well as training programmes. It isimperative that the transfer of skills necessary tocontinue providing the optimal treatment to ourpatients keeps pace with these changes and be readyto absorb ongoing advancements. As some one said‘‘future is not like it used to be’’! . This suggests that atleast some of the time honoured methods of teaching,training and assessing the transfer of skills needmodifications and changes. By looking into the pastwe can learn how we got to this point and have beencoping with the changes over the years. Thisundoubtedly help us to face the future with confidenceand progress further.

There can be no better place to start than with Susrutha– about 1500BC – who is now considered to be thefather of surgery. His practice of medicine was faradvanced for his time and the use novel ways oftraining enabled many who wished to learn the nobleart of healing at The University of Taxila whereSushrutha had set up an excellent training unit.

The Sushrutha Samhitha, his chronicles with morethan 120 chapters outlining diagnostic methods,medical treatment and surgical procedures is amasterpiece. In it the most interesting section is theone on surgical training. From selection criteria oftrainees to their induction, lectures and demonstrationon the anatomy and physiology of the human body

Dr. P. Sivasubramaniam Oration

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Training – How did we get here and where are we going?

are all dealt with in detail. It is the importance given bySusrutha to formal training, methods used to transferskills that I wish to highlight while drawing parallelsbetween the ancient Indian methodology and what wepractice now. Susruta describes concepts consideredmodern, such as antisepsis, anaesthesia, andpostoperative care. A direct translation from theoriginal Sanskrit describes the first record of extracapsular extraction at a time couching the cataract wasthe accepted practice to clear the visual axis. Thisclearly showed that he too developed and trainedhimself in a new surgical technique aiming to providea safer treatment to his patients. Visionaries like Drs.P. Sivasubramaniam, R. Pararajasegaram, UpaliMendis and Charith Fonseka have followed the samepath set by Sushrutha, Charaka and others, in order toensure that Ophthalmology continued to develop as aspeciality in Sri Lanka providing the best treatmentthrough competent practitioners well trained in the artof healing. Sushrutha is said to have paid equal attentionto treating patients and training his apprentices,assessing periodically his team thus emphasising theimportance of continued medical education andprofessional development of both the trainees and theirtrainers. This concept has come back into mainstreamthinking recently and is part of the annual appraisalprocess of all specialists in many countries. I am surethe Sri Lankan college too will put in place, if it hadnot already done so procedures to ensure their traineesare getting the best mentors who are up to date withtheir knowledge base and skills.

Let us see how what Susrutha pioneered set in motionchanges over the following centuries.

The concept and understanding of formal training aswell as the methods used to transfer skills reflectedthe needs of the society and facilities available.

During the medieval period the transfer of skills wasdirected mainly towards teaching scribes, philoso-phers, astronomers, those connected with law, religionand art. Teaching and training systems were runmainly by mentors.

Acquiring skills was based on a concept of ‘‘Look,Listen and Learn’’. It was often a long process but thementors transferred more than mere technical skillsand knowledge. The benefit of their experience thatcannot be gained by reading scripts and watchingothers was the greatest asset of this system despite aninherent drawback of lack of uniformity and personalbias.

Then came the wars and the industrial revolutionchanging the society, it’s structure and needs. Theemphasis on training was dictated by military systems,renaissance, industrial revolution and the birth oftrades and professions. Learning and training duringthis period was mainly by demonstration, explanationgroup learning, questioning and testing as well as somedegree of mentoring.

In the 19th Century learning became compulsorymainly in Europe. There was an element of authorita-rianism sticking to a rigid curricula involving detailedtheory and the effort was directed towards exami-nations which became important tools of assessmentof ability and skill.

Fortunately acquisition of skill still depended on anapprentice system providing guidance and advice toensure standards were maintained to some extent atleast. The value of experiential method-deriving,meaning and understanding from experience wasappreciated and well used.

Many inventions and new ways of diagnosing andtreating diseases created a demand for good ongoingtraining in these aspects of patient care. In 1850,Hermann von Helmholtz (1821-94), invented theinstrument which was to transform the practice ofophthalmology - the ophthalmoscope with it dawneda new speciality of Ophthalmology. He spoke of it asan ‘‘unfolding’’ and not an invention! Albrecht vonGraefe (1828-70) the famous ophthalmologist said‘‘Helmholtz has exposed to us a new world!’’

SUSHRUTHA SAMHITA-120 CHAPTERS

POSIBLY 10-6THBC.

• SUTHRA STHANA

• NIDHANA

• SARIRA STHANA

• CIKITSA STAHANA

• KALPA STHANA

• FUNDAMENTAL PRINCIPLES

• ETIOLOGY

• ANATOMY AND PHYSIOLOGY

• THERAPEUTICS

• TOXICOLOGY

TRAINING AND ATRIBUTES OF A SURGEON

SURGICAL INSTRUMENTS

OTHER NOTABLE

CHAPTERS

Importance given by Sushrutha to various aspects ofpatient care including training.

The evolution of the concept of training

There is evidence showing that Sushrutha Samhithawas translated by Caliph Mansour to Arabic enablingit's spread westwards very rapidly.

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20th Century saw rapid changes and inventions inthe field of ophthalmology and medicine in generalthat demanded updating for established ophthalmo-logists and well organised training for new trainees.This was met by the following:

• Expert teachers – ’’Trained trainers’’

• Enhanced knowledge base

• Updated textbooks

• Case study methods

• Learning by teaching

21st Century threw a different challenge driven byadvancing information technology. A wide range ofdata bases, search engines and a selection of usefulweb sites demanded emphasis on evidence basedpractice necessitating different type of training methodsand assessments. The main aspects of the training inthis ‘‘era of technology’’ laid emphasis on thefollowing;

• Use of leading-edge technologies

• To widen the knowledge base communicate andshare idea

• Training in new operating skills using novellearning methods

• Developing inter-professional teamwork

• Individual assessment-targeted learningdirected towards development

• Evaluation of outcomes, gap analysis and needsassessment

Technological advancements necessitated meticulousattention to be given to acquiring expertise in thefollowing aspects of using modern equipment toimprove patient care and also learn modern ways oftransferring skills such as using wet labs and simulatorexperience;

Imaging of the eye

OCT, Corneal topography

Video recording of surgery

Personal graphic records

Collaborative learning

Audit of surgical technique and outcomes

Wet lab practice

Simulation systems for virtual surgery.

Training on simulators can give certain degree offamiliarity and confidence with procedures but suchvirtual experience is no substitute for real surgery whichcan be gained with that experience under the guidanceof an expert mentor. Such methods are not entirely newas Sushruta developed an excellent wet lab techniquefor his trainees. The following extract from his chapteron training shows how much thought had been putinto training during his time.

Hermann von Helmholtz (1821-94) and his inventionthe Ophthalmoscope.

Susrutha’s Wet Lab-

• Incision and excision

• Scarping

• Veni puncturing

• Probing

• Scarification

• vegetables and leather bags filled with mud of different densities

• Hairy skin of animals

• Vein of dead animals and lotus stalks

• Moth-eaten wood/bamboo

• Wooden planks smeared with beeswax

This set the trend for generation and there is evidenceof instructions on intricate surgical techniques beingpassed down generation by word of mouth resultingin some finding their way into current surgical text.Bower Manuscript dated around 700 AD written onbirch bark referrs to Susrutha Samhitha in some detailand is a great source of valuable information.

The Susrutha Samahita lays down the basic principlesof plastic surgery by advocating a proper physiothe-rapy before the operation and describes variousmethods for repairing different types of defects, viz.,(1) release of the skin for covering small defects, (2)rotation of the flaps to make up for the partial loss and(3) pedicle flaps for covering complete loss of skin froman area. He has mentioned various methods includingsliding graft, rotation graft and pedicle graft.Reconstruction of a nose (rhinoplasty) which has beencut-off, using a flap of skin from the forehead and cheek

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Training – How did we get here and where are we going?

has been described in deail and is still an acceptedtechnique for reconstruction of midfacial defects. Theimportance given so many centuries ago, to goodtraining underpinned by sound knowledge andteaching methods is what helped surgical training ingeneral to evolve over the years.

Modern ophthalmologist needs to capitalise on theprogress that has been achieved over the years in orderto provide the best available care to patients. Thefollowing steps would help to reach that goal and meetall challenges.

• Ongoing knowledge acquisition using theavailable information technology

• Systematic skills acquisition and upgrading

• Annual auditing and recertification

• Subject to regular appraisals

• Aspire to provide the best quality of care at alltimes.

• Strong ethical framework

Quality being a journey and not a destination, trainingand skills acquisition should also be on going if thebest care is to be provided.

Ophthalmic learning and acquisition of skills are verymuch dependent on just not the trainee but equally onthe trainer as well and the hallmark of a good trainerand trainee can be summed up as follows;

Trainer

Generosity of spirit

Time commitment to teaching

Well trained themselves with regular updating

Trained in best teaching practice to facilitate thelearning.

Trainees

Committed, passionate

Self-motivated to learn

Have an insight into the art of healing.

The examples set by Sushrutha and those whofollowed him confirm that the best way to learn is byhaving a good mentor. There is more than justknowledge and technical skills to acquire during thetraining period. It is essential to understand theimportance of treating the patient and not just thedisease. A good mentor is the best guide to provide amultifaceted approach to learning this great art.

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A preliminary morphometric study of the human bonyorbitA. K. G. Withana, W. S. Weerasinghe, K. A. Salvin

The Journal of the College of Ophthalmologists of Sri Lanka 2014; 20: 28

1Department of Anatomy, Faculty of Medicine, University of Kelaniya, Sri Lanka.

Introduction

Human orbital morphology is of much functional andclinical significance. Seven bones are involved in theformation of the bony orbit namely, maxillry, frontal,ethmoid, zygomatic, sphenoid, lacrimal and thepalatine bones1. Orbit resembles a quadrilateralpyramid whose base is directed forward laterally andslightly downward whose apex is between the opticforamen and medial end of the superior orbital fissure1.

The importance of the anatomy of the orbit ishighlighted in subjects related to clinical anatomy,reconstruction surgery and forensic medicine2,3. Thedimensions are used in reconstruction protocols usedin archeological research. Its dimensions have beenstudied using the imaging modalities but anatomicalstudies using dry bone are less observed in theliterature. Therefore it is evident the need of such studiesin the local context.

Objective

This anatomical study was carried out in Faculty ofMedicine, University of Kelaniya using the dried skullcollection maintained in the anatomy museum.

The objective of this study was to describe selectedmorphometric dimensions of the bony orbit in a sampleof Sri Lankan skulls. Ethical clearance was obtainedby the Faculty of Medicine Ethical Review Committee.

Methods

Twenty four dried, intact and complete human skullswhich are not eroded were studied. Morphology oforbits with the presence or absence of orbital canal,superior and inferior orbital fissures and ethmoidalforamina, inter orbital distance (A), maximum distancebetween lateral edge of orbits (B), the maximum vertical(C) (supra orbital ridge to infraorbital ridge) andhorizontal length (D) (edge of frontomaxillary sutureto edge of frontozygomatic suture in the margins oforbit) were measured using a standardized Verniercaliper (minimum reading of 0.1mm). Shape of the orbitwas considered as quadrangular if the percentage ofdifference between the maximum vertical andhorizontal diameters is less than 10 percent.

Results

Ninety percent (44) of orbits were quadrangular inshape. Foramina observed in each orbit demonstratedvariations in the shape, sizes and axes. The mean interorbital distance was 1.9±0.04 cm. The mean maximumvalue for B was 9.7±0.52 cm. The mean (R) maximumhorizontal diameter was 4.1±0.12 cm and (L) 3.9 ± 0.14cm. The mean maximum vertical (R) diameter was3.5±0.33cm and (L) is 3.4±0.22 cm. The mean ratio ofC/D is 1.17 (R); 1.14 (L).

Discussion

The anatomy of the bony orbit is fundamental tounderstand the clinical interventions and applicationsin the facial skeleton. Our findings are based on alimited sample size and needs to incooperate more todenote a general figure that can be applied to the localpopulation. Such generalized figures help in moreclinically oriented studies of this important region.

Conclusion

The results of this study are compatible with thefindings of anatomical and radiological morphometricvalues of the bony orbit and warrant further studies.

References

1. Standring Susan; Gray’s Anatomy, 39th Edition, Elsevier.

2. ChristophHintschich, FransZonneveld, FransZonneveld,LelioBaldeschi, CateyBunce, Leo Koornneefl. Bony orbitaldevelopment after early enucleation in humans. Br JOphthalmol 2001; 85: 205.

3. Tuncer, Serhan, Yavuzer, Reha, Kandal, Sebahattin, Demir,Yucel H, Ozmen, Selahattin, Latifoglu, Osman, Atabay,Kenan. Reconstruction of Traumatic Orbital Floor FracturesWith Resorbable Mesh Plate. Journal of Craniofacial Surgery2007; 18(3): 598-605.

4. Chen Z1, Zheng XH, Xie BJ, Yuan JJ, Yu HH, Li SH. Studyon the growth of orbital volume in individuals at differentages by computed tomography. Zhonghua Yan KeZaZhi2006; 42(3): 222-5.

5. Richard MJ1, Morris C, Deen BF, Gray L, Woodward JA.Analysis of the anatomic changes of the aging facial skeletonusing computer-assisted tomography. Ophthal Plast ReconstrSurg 2009; 25(5): 382-6.

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Pupil – some interesting aspects

Pupil – some interesting aspectsK. Puvana Chandra


Introduction

Pupil which was largely considered as an aestheticaspect of the eye gained functional importance onlywhen the physiology of vision and the optical functionof the eye began to be understood.

Plato in the fourth century B. C., thought that lightemanated from the eye, seizing objects with its rays.He thought that the eye had‘’a fire within.’’‘‘extramission’.’ Aristotle advocated a theory of‘‘intromission’’ by which he said that the eye receivedrays rather than directed them outwards.

In 1604, Kepler, postulated that vision occurred whenthe image of an object formed a picture on the concavesurface of the retina. The eye was compared to a cameraobscura and pupil gained optical importance as a stopin this optical system.

Changes in the pupillary diameter due to fluctuationsin the level of illumination was thought to be a directresponse to the intensity of light aimed at adjustingthe required level of light entering the eye but detailassessments suggested otherwise.

Area of the pupil when fully dilated is only 16 timesbigger than when it is fully constricted. The range ofluminance that the visual system can deal with fromthe dimmest lights that can be detected up to intensitiesthat will start to damage the retina is about 10 000 000000: 1. It became evident that the main function of the

Consultant Ophthalmologist, Department of Ophthalmology, Norfolk and Norwich University Hospital, Norwich, U.K.

pupil is not controlling the amount of light enteringthe eye but to influence the quality of the image formedon the retina, like the aperture in a sophisticatedcamera. In photography pictures taken with a smallaperture have a greater depth of focus than picturestaken with a large aperture. A pinhole camera withoutany lens systems projects images where everything isin focus, regardless of the distance. The same is truewith the pupil as when it constricts the depth of focusincreases.

The quality of the image falling on the retina isdependent upon a number of factors. The opticaltransfer function (OTF) of an imaging system like thecamera, a microscope or the eye is the true measure ofthe image sharpness that the system is capable ofproviding. The cornea and the lens are the majorcomponents in the eye contributing to the OTF of the eye.

Modulation Transfer Function (MTF), the magnitudecomponent of the OTF that is most relevant indetermining the real quality of the image is influencedmainly by the pupillary size, retinal integration andneural processing. The Stiles-Crawford effect of the firstkind dependent on the pupillary diameter influencesthe MTF.

The point spread function (PSF) which reducesdiffraction and distortion has a significant effect onthe quality and sharpness of the image. It is largelydependant on the size and shape of the pupil.

Normal eye Perfect Eye

PSF & Pupil size- Normal eye

Point spread Function & Pupillary sizes

30


The shape and size of the pupil along with it’s ability to alter the size therefore influences significantly the qualityof the image formed by the optical system of the eye.

The wide rage of shapes and sizes of the pupils in the animal kingdom possibly initiated as gene mutations seemsto have influenced evolutionary steps leading to natural selection. There must be functional benefits suited totheir specific habitat.

Many surgical techniques and devices are available to rectify pupillary distortions and minimise their effects onthe quality of the imaging and at the same time give an improved cosmetic effect as well. Surgical and laserpupiloplasty, use of suitably painted contact lenses and implant that partially or totally provide an iris diaphragmsare available to achieve this.

The pupil in the human eye can be distorted due to a variety of causes.

Distorted/Abnormal Pupils

Congenital

Post inflammatory

Iatrogenic

Traumatic

Implants are not blameless!

Round peg in a square hole!“Shape changers”

Painted contact lensPainted contact lens

AniridiaAniridia cont….cont….

Left eye with axial cataractLeft eye with axial cataract Painted IOL with optical Painted IOL with optical correctioncorrection

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Pupil – some interesting aspects

The size of the pupil can reflect more than its opticalqualities. Pupil dilation reveals state of excitementwhen one might wish to conceal it. And for this reasongambler’s use an eye shade to prevent opponentsgaining a clue. Jade dealers have long examined thepupils of prospective customers – look for any pupildilation and will push up the asking price, in theknowledge that the customer is interested!

Clinically checking the pupillary response to light isan interesting and instructive exercise giving valuableinformation, if done correctly.

When looking for RAPD it is important to move thelight from one eye to the other eye quickly within 1second and holding a 3 second pause in each eye.

This technique is reliable in detecting and quantifyingthe relative afferent pupillary defects. Using filters canhelp to reveal subtle, early RAPDs.

One should look for the difference in amplitude of theinitial consensual pupillary constriction versus theinitial direct pupillary constriction. An examinershould diagnose an RAPD when the amplitude ofconsensual pupillary response is greater than thedirect response.

In a normal pupil, a 0.3 log unit neutral density filterdoes not enhance or change it’s responses. It isimportant to use the same amount of light directed toapproximately the same retinal area and for the same

amount of time with steps being taken to eliminate anyinduced pseudo-afferent pupillary defect such as anear response. Sometimes, it is difficult to differentiatea hippus from a RAPD.

Hippus is a normal fluctuation in pupillary size understeady illumination and it should be equal inamplitude between two eyes to qualify as a normalvariant.

Any difference in ‘‘the hippus amplitude’’ betweentwo eyes suggests a subtle RAPD.

The take home message is ‘‘Note the amplitude of thepapillary response to light and not just whether it isconstricting or not’’.

Conclusion

Pupil, just an empty space in the eye with no structureor tissue, has interested anatomists, physiologists,clinicians, scientists and artists alike over the years.It’s contribution to the quality of the image falling onthe retina cannot be underestimated. Testing the rate ofchange in it’s size in response to varying physiologicalstimuli as a diagnostic tool in the management ofneurological and other diseases is of great value. Thestudy of this small entity in the eye never stopsfascinating the ophthalmologists and with newknowledge and improved techniques of testing beingbrought in it will always remain an interesting topicfor discussion.

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Current glaucoma surgeryDeven Tuli


Introduction

For past few decades, the only option considered for the first surgical approach to lowering significantly highintraocular pressure (IOP) was trabeculectomy (trab). However, the variable immediate post operative course,including overfiltration and resulting hypotony and shallow AC in some eyes and underfiltration and highpossibility of tissue scarring and resulting long term failure makes trabeculectomy an unpredictable surgery inbest skilled hands. Hence, over the past few years, numerous techniques have been introduced as alternative totrabeculectomy.

Lens removal

Phacoemulsification has been shown to lower IOP1. However, the effect in eyes with OAG is small and may not belonglived, and will rarely deliver the low enough IOP that many surgeons desire for their glaucoma patients. InACG situation, lens removal may obviate the need for laser PI, in a patient with significant cataract, planned forphaco. In certain ACG patients, the lens complex bulk may itself be the cause of angle narrowing and in thesesituations, benefit of lens removal is definite. But as a whole, for patients with bona fide glaucoma with visualfield loss, cataract surgery alone is not the best option for lowering IOP.

Trabectome and canaloplasty

Trabectome and canaloplasty are recent techniques that can lower IOP without producing a filtration bleb – It isconsidered the site of scarring and failure of most trabeculectomy. Trabectome surgery (Figure 1, 2) removestrabecular meshwork and inner wall of Schlemm’s canal from an ab interno approach using a special device. Itspares conjunctiva for possible future glaucoma surgery and can be done in phakic and pseudophakic eyes.However, it does not often result in IOP low enough and is not suitable for eyes beyond moderate glaucoma.

Consultant Glaucoma Delhi, Fellowship Glaucoma AIIMS, India, Fellowship Glaucoma USA.

Figure 1 and 2. Trabectome and ab interno trabectome surgery.

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Canaloplasty (Figure 3, 4), involves threading through the Schlemm’s canal, a special probe like device that maybe guided with light. Like trabectome, it does not produce a bleb, but does require significant conjunctival andsclera surgery, reducing virgin conjunctiva for future surgery. And is similar to trabectome, will not producereally low IOP.

Figure 3 and 4. Canaloplasty and canaloplasty surgery through schlem’s canal.

Endolaser cyclophotocoagulation

Endolaser cyclophotocoagulation (ECP) (Figure 5, 6) of the ciliary processes is a definite improvement over externalcyclophotocoagulation and cyclocryotherapy. ECP is not possible in phakic eyes, and in general currently isprecluded as a primary first glaucoma intervention owing to its destructive and irreversible nature.

Figure 5 and 6. ECP probe and ab interno ECP of ciliary processes.

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Express mini shunt

Express mini shunt (Figure 7, 8) is really just a variation on trabeculectomy. One is still creating an opening in thesclera covered by a partial thickness scleral flap, and the formation of a bleb is an integral part of the operation.The Express mini shunt does eliminate the need to excise a piece of the sclera (inner sclerostomy) and the need toperform an iridectomy. Also in general, Express eyes have a lower incidence of early postoperative hypotony andshallow AC2. Flip side is that we are introducing a metallic implant into the eye and the high cost. It is best avoidedin patients with ACG and eyes requiring significant drop in IOP from pre-op levels.

Figure 7 and 8. Express mini shunt in situ.

Glaucoma drainage device (shunts)

Glaucoma drainage device (GDD) surgery certainly merits consideration as the second glaucoma surgery if trabfails in primary glaucoma cases. It is considered ahead of trab in certain situations such as:

a. Neovascular glaucoma with extensive rubeosis

b. Post keratoplasty glaucoma

c. Post vitreo-retinal surgery glaucoma

Whether GDD or tube surgery could be the initial incisional surgery for glaucoma. To answer this, following onthe heels of the Tube vs. Trabeculectomy study, the Primary Tube vs. Trabeculectomy (PTVT) study is nowunderway to answer precisely the question i.e. which is the better primary operation, tube or trabeculectomy? Feelthat until we have the results of the PTVT study, we should continue to regard trabeculectomy as our initialsurgical approach for most types of glaucoma. Reservations about GDD surgery as initial surgery are:

a. There are unresolved concerns about the long-term effect of tubes in sustained IOP control and upon thecornea3.

b. The ability to titrate by use of suture release techniques in trabeculectomy and post-operative use ofantifibrosis agents gives the surgeon the power to modify a trabeculectomy after surgery, an opportunitynot usually possible with GDD.

Two GDD currently available in India are the

a. Ahmed Glaucoma Valve (AGV) (Figure 9, 10): As the name suggests is a valved implant, so initialoverdrainage is not seen in every case. There is a hypertensive phase that occurs due to scarring around thebase plate, usually seen 4 weeks to 4 months after and lasts 3 weeks to 3 months.

b. AADI (Aravind Aqueous Drainage Implant) (Figure 11, 12): Developed in India by the Aravind group, thisis a non valved implant (on Baerveldt principle) and suffers from inevitable hypotony and shallow ACinitially that needs to be controlled by ligating the tube for 6 weeks. So IOP remains high for that period butin the long term the IOP control is superior.

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Figure 9 and 10. AGV adult model, in situ.

Conclusions

The procedures mentioned in this article are continually being further refined and hopefully in future will offergood choice glaucoma surgery that is predictable, reproducible, safe and effective. However, with the current stateof the art, it is still trabeculectomy, that has the best risk/benefit ratio4. For that reason, trabeculectomy still reignshigh when it comes to the initial surgery treatment of glaucoma. Judicious use of mitomycin C (MMC) 0.1-0.4% for1-3 min depending on target IOP for that eye and augmenting Trab with releasable sutures is the current practise.Follow up needling and/or MMC in post operative period for cases showing extravagant healing is recommended.

References

1. Shingleton BJ, Pasternack JJ, Hung JW, O’Donoghue MW. Three and five year changes in intraocular pressures after clear cornealphacoemulsification in open angle glaucoma patients, glaucoma suspects, and normal patients, J Glaucoma 2006; 15: 494-8.

2. Maris PJ, Jr, Ishida K, Netland PA. Comparison of Trabeculectomy With Ex-PRESS Miniature Glaucoma Device ImplantedUnder Scleral Flap. J Glaucoma 2009; 18: 488-91.

3. Lee EK, Yong WJ, Lee JE, Yim JH, Kim CS. Changes in Corneal Endothelial Cells after Ahmed Glaucoma Valve Implantation:2-Year Follow-up. Am J Ophthalmol 2009; 148: 361-7.

4. Stein JD, Ruiz D Jr, Belsky D, et al. Longitudinal rates of postoperative adverse outcomes after glaucoma surgery amongMedicare beneficiaries 1994 to 2005. Ophthalmology 2008; 115: 1109-16.

Figure 10 and 11. AADI model, in situ.

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Evaluation of the successfulness and complications of enucleationsurgery with acrylic orbital implant covered with human scleraPradeepa Bandara1, Eranga Jayasinghe2, Sadana Ekanayake3, N. Kaleivarden4, Tissa Senarathne5, SamanSenanayake6


Introduction

Losing of an eye can be devastating at any age. It mayhave a major impact on one’s self image, and self esteem.The effect on cosmetic appearance may cause manypsychosocial problems and affect badly to their qualityof life. After enucleation and evisceration the socketloss become another potential problem. Volumereplacement with orbital implant provides cosmeticallygood eye with proper mobility.

There are many people in our community, who arehaving non functioning cosmetically bad eyes due totraumatic and nontraumatic causes. Specially manyyoung patients following RTA and war injuries. Mostof these patients offer Evisceration or Enucleation withprosthesis without orbital implants. In most of the casesthe limiting factors is its high cost.

In our study a modified standard enucleation usingcost effective acrylic implant covered with patient’sown sclera or donor sclera was used in order to insertlarge porous expensive orbital implant.

This is very cost effective surgery, than currentlypopular other orbital implants.

There are limited scientific evidences on outcome ofenucleation surgery with acrylic implants covered withhuman sclera.

An ideal orbital implant should offer excellent motility,good cosmetic outcome with few complications.

Currently available orbital implants are

1. Porous implants –

Made of porous material. Blood vessels and tissuesgrow into the porous structure. These implantscan be pegged and give good motility. The maindisadvantages are high risk of infection andextrusion. Also these implants are very expensive.Eg: Hydroxy appetite (Bio Eye), porous polyethtine(med por), aluminium oxide (bio ceramic).

1Registar, 2,3,4Medical Officer, 5,6Consultant Ophthalmologist, Teaching Hospital, Kandy, Sri Lanka.

2. Nonporous implants –

Made of non porous material (usually acrylic). It isthe most basic simple implant. Therefore to get themotility, the implant has to wrapped with scleralshell or other bio materiel. If not, the implant willfloat freely in the orbit. This is a low cost productand less chances of extrusion and infection. Siliconimplants are also non porous but more pliable thanacrylic. Glass also can be used as orbital implantmaterial.

3. Dermis fat graft is another method –

Fat from around the navel area or buttock is used tofill the orbital cavity. It is inexpensive, very low riskof exposure and these grafts can grow with the child.Disadvantages are atrophy which can occur withtime and cosmetically.

The tissues that can be used to cover the implant

• Autogenous fascia/sclera• Cadaveric sclera/fascia• Bovine pericardium• Synthetic material such as poly galactine mesh.

The autogenous sclera or cadaveric donor sclera, wasused in these patients with cost. Placement of orbitalimplants within the sclera (with 14 - 16 mm diameterimplants) will help to maintain the socket volumesuperior sulcus depression and secondary eye lidmalposition.

General objective

To evaluate the outcome and effectiveness of acrylicorbital implant covered with human sclera.

Specific objectives

1. To evaluate cosmetic outcome of enucleationsurgery with acrylic orbital implant

2. To assess patient satisfaction after surgery

3. To observe postoperative complications of thesurgery.

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Evaluation of the successfulness and complications of enucleation surgery

Methodology

The study is conducted at Center for Sight (Eye Unit),Teaching Hospital Kandy. The type of surgery, benefitsand complications of surgery was explained andinformed written consent was obtained before doingsurgery, data was collected postoperatively.

Study design

This is a prospective consecutive case series of patientsunderwent enucleation with acrylic orbital implantcovered with human sclera. It is a prospectivedescriptive study, with description of cosmeticoutcome, patient satisfaction and complications ofsurgery.

Exclusion and inclusion criteria

Inclusion criteria –

1. Patients with non functioning cosmetically badeyes who underwent enucleation surgery withacrylic orbital implant, attending eye clinic oradmitting to eye ward TH Kandy

2. Patients who give consent for study

3. Patients between age 14 and 70

Exclusion criteria –

1. Patients who do not give consent for study

2. Patients who are having ongoing eye infectionor systemic infection

3. Patients who had severe orbital trauma andextra ocular muscles were not identified.

Ethical clearance

Ethical clearance obtained for the study from theresearch and ethics committee of T H Kandy.

Surgical procedure

The surgery was done under general anaesthesia orretrobulbaranaesthesia. As the 1st step, 360 degreeperitomy was performed at the corneal limbus,preserving as much as healthy tissue possible.

Then tenon fascia was separated from the sclera byblunt dissection. Four recti muscles were identified andsutures were placed in the recti muscles at theirinsertion into the sclera, to secure the muscles. Thenthe muscles were detached from the globe. Both obliquemuscles were cut off. Standard enucleation wasperformed and optic nerve was transected.

In the accessory surgical table the removed globe wasprepared to get clear scleral cover, by removing corneaand uveal tissue. If the scleral cover was not enough to

accommodate the orbital implant, used a donor sclerawhich were got down from the eye bank. The acrylicball was inserted to the scleral cover.

Corneal opening was sutured with non-absorbablepermanent suture (5.0 Ethebond) to completely coverthe implant.

Now it was ready to implant into the orbital cavity.The optic nerve side of the sclera was kept anteriorly(the sutured scleral opening was placed posteriorly)and inserted into the enucleated orbit. This methodreduces the dislodgement of the acrylic ball postoperatively.

four recti muscles are sutured to the sclera separately,more anterior to the equator, (using 5-0 Vicryl). Thenconjunctiva closed with continuous suture (using 8-0Vicryl). Finally a shell shaped artificial eye fitted overthis implant and temporary tarsorrhaphy done for 2-3weeks to secure the artificial eye.

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This procedure allow satisfactory movement of external prosthesis because of the four rectus muscles are suturedto the sclera and because of this technique the orbital volume is completely filled. All the patients are followed upat 1st week, 4th week, 2nd month and 6th month at the end of 1st year. We assess the successfulness of surgery bysocket fullness and eye movements. Complications of surgery are infections, dislodgement of the implant andscleral graft rejection. We also assessed patient and family satisfaction after surgery.

Patient 1. 32 yrs from Jafna war injury to L eye.

Patient 2. 17 yrs, from Hingurakgoda had trauma to L eye, PKP done, but graft rejected, ended up as NPL eye.

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Patient 3. 16 yrs from Kurunagala trauma to R eye at 6 yrs.

Patient 4: 76 yrs from Kasiwatta trauma to R eye at 20 yrs.

Discussion

In our study we showed that low cost acrylic ball orbitalimplant can be used successfully to prevent socketvolume loss, superior sulcus depression andsecondary lid malposition. It has allowed well fittingof the external prosthesis. It provides better eyemovement and good cosmetic appearance.

Comparing with other orbital implants cost of theacrylic ball is very low. Our surgical procedure wassafe and effective. Not a single case found with implantrejection, dislodgement or major infection notedfollowing one year after the surgery. The levels ofsatisfaction of patient were very high.

This surgery can performed in peripheral hospitalswith minimal surgical facilities.

References

1. Zagoti GL, Cavarreta S, Morara M, Nam S M, Ranno S, PichiF, Lembo A, Lupo S, Nucci P, Meduri A. Slanderedenucleation Standard Enucleation with Aluminium OxideImplant (Bioceramic) Covered with Patient’s Sclera, ScientificWorld Journal 2012; 2012: 481584. Published online 2012April 30. doi: 10.1100/2012/481584.

2. Goldberg RA, Holds JB, Ebrahimpoure J. Exposedhydroxyappetite orbital implant. Opthalmology: report ofsix cases. Opthalmology 1992; 99(5): 831-6.[pub med].

3. Kim YD, Goldberg RD, Shorr N, Steinsapir KD. Managementof exposed hydroxyappetite Orbital implants.Opthalmology 1994; 101(10): 1709-15 [Pub Med].

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Disc haemorrhage and the progression of glaucoma – an experienceC. Kumarage1, K. H. Wickramasinghe2, J. G. Mahesh3, D. H. H. Wariyapola4


Introduction

The presence of disc haemorrhage is a risk factor forglaucoma and is considered as a non specific sign ofglaucomatous disc damage. It may also be a marker ofinadequate control. It also signifies progression ofestablished disease. When disc haemorrhage is presentin a glaucoma suspect patient should we diagnoseglaucoma early? And should we escalate follow upand treatment in established glaucoma? We present apatient who had progressive disease presenting withdisc haemorrhage.

Case details

Female, aged 67 years was initially seen two and halfyears ago. The optic disc and fundus did not showany glaucomatous damage, except for the presence ofa solitary disc haemorrhage. Patient did not have

1 Registrar, 2Post Graduate Trainee, 3Senior Registrar, 4Consultant Ophthalmologist, Eye Unit, Sri JayawardenapuraGeneral Hospital, Kotte, Sri Lanka.

hypertension and diabetes and was not on any antiplatelet medication. Review in one year and two yearsshowed progressive glaucomatous damage to the opticdisc, with cup disc ratio of 0.65 bilaterally, with opticalcoherance tomography retinal nerve fibre layer andganglion cell analysis all showing glaucomatousdamage.

Discussion

Significance of disc haemorrhage in glaucoma has tobe factored with the presence of any concurrenthypertension, diabetes and anti platelet therapy. Ahigh index of suspicion for early diagnosis and regularfollow up is necessary in glaucoma suspect patientswith disc haemorrhage. In established glaucoma tightercontrol and closer monitoring is necessary as it maysignify that active progression of glaucoma is likely.

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Disc haemorrhage and the progression of glaucoma - an experience

Fellowship Awards

Presenting, Mr. Kathir Puvanachandra for the conferment of the honoraryfellowship of the College of Ophthalmologists of Sri LankaThe Journal of the College of Ophthalmologists of Sri Lanka 2014; 20: 41-42

Mr. Chandra is presently working as a consultant ophthalmologist at Norfolk and Norwich University TeachingHospital, NHS foundation Trust, United Kingdom and also as a honorary lecturer at University of Wales Medicalschool, Cardiff. He graduated from the Colombo Medical College in 1971 and initiated his opthalmic career at theColombo Eye Hospital.

In 1988 he left Sri Lanka for post-graduate training at the Sydney Eye Hospital and Norwich and Glasgow eyeunits in UK.

Working as a consultant ophthalmologist, Mr. Chandra, was instrumental in developing an excellent eye unit atHM Stanley Hospital in the picturesque city of St. Asaph, North Wales between 1984 and 2010. This opthalmicunit gained national recognition as an excellent training unit for British trainees and many oversees traineesincluding a number of Sri Lankan Ophthalmologists.

He has put forward many publications and posters which appeared in the Royal College Eye Newsletter, BritishJournal of Ophthalmologists, British Journal of Anaesthetists, British Oculoplastic Society meeting at OxfordCongress and many other meetings.

It would be amiss of me if I don’t comment on his brilliance as an anterior segment surgeon who can deal withmany complicated ophthalmic situations. Moreover, his skillful hands are successfully put to use as a posteriorsegment surgeon when called upon as well.

His keen interest in training, teaching and examinations is showcased by his involvement in many committees ofthe Royal College of Ophthalmologists, UK.

Since 1989, Mr. Chandra has served as an examiner for the Royal College of Ophthalmologists, Glasgow and atseveral occasions he has also served as the external examiner for the College of Ophthalmologists of Sri Lanka.

When the Royal College of Ophthalmologists decided that the dual sponsorship scheme should be cancelled itwas the great effort of Mr. Chandra that kept it functioning. He accomplished this while he was the chairman ofthe international medical graduate training committee from 2002 to 2010. As a result, during the last 10 yearsnearly 25 Sri Lankan Ophthalmologists were fortunate enough to get their oversees training in the United Kingdom.

Some of the ophthalmologists who are gathered here today including Mr. President and I know how he helped usin every possible aspect during our stay in the UK. Mr. Chandra, we are truly indebted to you for all you havedone.

Mr. President without any doubt he has enabled all his trainees to become fine ophthalmologists back here, in ourcountry and therefore his contribution to the College of Ophthalmologists, Sri Lanka is immense. I honestly couldnot think of a candidate who deserves this honorary fellowship from the College of Ophthalmologists in SriLanka more than Mr. Kathir Puvanachandra.

Mr. President I proudly present Mr. Kathir Puvanachandra for the conferment of the honorary fellowship from theCollege of Ophthalmologists of Sri Lanka.

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Presenting, Dr. (Mrs.) Daya De Silva for the conferment of the honoraryfellowship of the College of Ophthalmologists of Sri Lanka

She had been born to respectable parents Mr. and Mrs. Lokubalasooriya of Katunayake. Being the second siblingin a family of six, she was sent for her early education to Madya Maha Vidyalaya, Veyangoda and later to VishakaVidyalaya in Colombo.

This was followed by her secondary education and entered the Faculty of Medicine in the University of Colomboin 1969. I need not elucidate of her capacity for studies as she had shown a bright capacity for her studies whichmade her attain second class honours in second, third and also in the final MBBS when she graduated in 1974.

Her intern periods were completed in university professorial units of LRH and DMHW.

Post intern period were in National Hospital of Sri Lanka, or, the then General Hospital Colombo, (ColomboAccident Service, Colombo Cardiology unit), and Colombo Eye Hospital.

Subsequently, she was awarded a full scholarship in Japan at Hirosaki University in 1981. She studied FA andLaser therapy in those days, under the guidance of Professor Matsuyama.

She obtained her ophthalmology diploma in 1986, and MS in 1990.

Her overseas training in Ophthalmology was with Dr J. Kansky, in King Edward VIIth hospital in Windsor, UK.

She started her career as a consultant eye surgeon in 1993, from Teaching Hospital Ragama. In 1996, she wasappointed to Colombo Eye Hospital. Here she remained till she retired from the Government Service in 2006. From2003 till her retirement, she was also functioning as the acting director at Colombo Eye Hospital.

She was first a member and then the Chairperson in Board of Study in Ophthalmology. She was the President ofthe College of Ophthalmologists of Sri Lanka in the year 2002.

From the beginning of her career as a consultant ophthalmologist she was a great teacher. We who were lucky towork with her knew that she would instill and develop a great trust of capabilities in the trainee's mind. She hada customized plan for each and every trainee that came in her way. Above all she was motherly and alwaysunderstanding in trainees’ issues. This quality manifested highest when she assumed duties as Eye Hospitaldirector. She was moving along with every category of staff, and she ran the administration with the goodwillof all.

She is married to Mr. Premlal Desai De Silva, who has been her real strength. And they are the proud parents ofDr. Damitra Udayanga De Silva.

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Cutaneous leishmaniasis, a differential diagnosis for eyelid lesions

Cutaneous leishmaniasis, a differential diagnosis for eyelid lesionsM. R. C. K. Bandara1, M. Gamage2, S. Nanayakkara3


Objective

To report a case of periocular cutaneous leishmaniasisto improve awareness among ophthalmologists.

Case: A 61-year-old Mrs. S from Colombo districtpresented to our clinic with a referral from a fellowophthalmologist. She had had a incisional biopsy froma lesion in her right lower lid.

History

Mrs. S complained of having a lump in her right lowerlid for 6 month duration. Its origin was more insidious.The lesion was noticed to grow slowly and laterdeveloped a central crusting. It was claimed to bepainless and none irritating. She had no associatedeye symptoms and also denied any similar lesionelsewhere in the body. She has had no trauma to theregion. Mrs. S was otherwise healthy.

1Senior Registar, 2Consultant Ophthalmologist, 3Consultant Pathologist, National Eye Hospital, Colombo, Sri Lanka.

Examination

The lesion was in outer part of the right lower lid. Itwas flat nodular and measured 1.6 cm long and 1.1 cmwide. It looked slightly erythematous but had notelangiectic vessels on the surface skin. Center of thelump was dry ulcerated. It was not tender to touch andhad no attachments to deeper structures. There wasno regional lymph node enlargement.

Differential diagnosis

1. Basal cell carcinoma

2. Granuloma

3. Foreign body granuloma

4. Chronic Inflammatory lesion-TB, Sarcoidosis

Management

Initial incision biopsy revealed inflammatory lesion.However since it was slowly enlarging with centralulceration and also due to patients concern we decidedto do completely excision. It was surgically excised,under local anesthesia. 1mm free margin was keptfrom the lesion to surgical incision. The specimenwas marked with suture to orient its sides and sentto histopathology lab in formal saline for filledcontainer.

Routine paraffin section and pathological examinationwas carried out. Haematoxalin and eosin stainingshowed a garulomatous inflammatory infiltrateconsisting of lymphocytes, histiocytes, plasma cellsand giant cells. Leishman-Donovan bodies wereobserved in the cytoplasm of macrophages. There wasno evidence of dysplasia or malignancy.

Diagnosis

Following histological examination, the case wasdiscussed with a dermatologist. Preoperative appearanceof her lid lump was described as typical nodularulcerative type cutaneous leishmaniasis. Managementof choice for this kind of lesion is medical. Since wehave completely excised it was decided to observe forrecurrence without further intervention. Subsequentinquiry revealed that patient visited her native placein Polonnaruwa almost in every month.

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Discussion

Leishmaniasis is a parasitic disease caused byLeishmania; a flagellated protozoa transmitted by thebite of some sand fly species and affects various agegroups. Depending on the infecting Leishmania speciesand host immunocompetence, there are cutaneous(CL), mucocutaneous, and visceral forms of the disease.It is estimated that 350 million people are at risk ofleishmaniasis. Approximately 12 million are affectedand 1.5 to 2 million infected each year. The disease ismore common in developing countries. The first locallyacquired cutaneous leishmaniasis was diagnosed in1992 in southern Sri Lanka. Cutneous Leishmaniasisis now endemic in Sri Lanka, with more prevalence inthe north central and southern provinces. The straincausing endogenous CL was characterized asLeishmania donovani zymodeme MON-37 (Karunaweeraet al 2003).

The clinical presentation of cutaneous leishmanisis isvaried ranging from asymptomatic papules, nodules,nodular ulcerative lesions and non healing ulcers. Theyenlarge slowly and will resolve spontaneously overmonths leaving an atrophic scar. It commonly affectsthe exposed sites and eye lid lesions are consideredrare.

The lid is involved only in about 2 to 5 per cent of casesof cutaneous leishmaniasis, probably because themovements of the lids prevent the fly-vector of thedisease from biting the skin in this region. Cutaneousleishmaniasis of the lid may also occur in mucocu-taneous leishmaniasis due to L. braziliensis, the infectedmaterial reaching the lid from nasal mucosal lesionthrough the nasolacrimal duct. Clinical diagnosis ofocular leishmaniasis is very difficult, since it maysimulate other more common lesions, such as recurrent

chalazion, and tumors, such as basal cell carcinoma,especially its ulcerative form. Differential diagnosismay also include other conditions, such as dacryo-cystitis, tumors, eczema, tuberculosis, syphilis,sarcoidosis, keratoacanthoma, histoplasmosis, andrhinoscleroma.

The diagnosis of CL is mainly clinical aided byparasitological confirmation. Haematoxylin-eosin andGiemsa staining revealed granulomatous inflamma-tion and macrophage-filled amastigotes. Cultureexamination on Novy-MacNeal-Nicolle medium andPCR amplification of parasite genes is also useddiagnostically.

The gold standard treatment for CL intra lesional orintra muscular sodium stibogluconate. If eyelid lesionsremain untreated, contiguous spread may extend tothe conjunctiva, episclera, and cornea, with develop-ment of interstitial keratitis. Residual scarring and liddeformity may require surgical correction. Therefore,ocular leishmaniasis is considered potentially ablinding disorder.

Conclusion

Clinicians working in endemic areas must keep inmind that a high level of suspicion to the diagnosisof cutaneous leishmaniasis and its rigorous treatmentis required in order to prevent complications of thispotentially blinding disorder. It is advisable to com-municate with dermatologist and pathologist foraccurate diagnosis of suspicious cases. Surgicalexcision is usually not indicated in cutaneousleishmaniasis. Leishmaniasis is a nortifiable diseasein Sri Lanka.

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A rare vitreo retinal dystrophy - juvenile retinoschisis

A rare vitreo retinal dystrophy – juvenile retinoschisisJ. G. Mahesh1, N. Attapattu2, K. H. Wickramasinghe3, D. H. H. Wariyapola4


Introduction

Juvenile retinoschisis is a form of x linked recessivebilateral familial vitreo retinopathy occurring in males,characterized by foveal schisis and peripheral schisisin about 50% of patients. The primary defect is in themuller cells causing splitting of the retinal nerve fibrelayer from the rest of the sensory retina which shouldbe differentiated from acquired retinoschisis where thesplitting occurs at the outer plexiform layer. Wepresent a patient with juvenile retinoschisis.

Material

A male aged 22 years complained of poor visionsince childhood. Vision was 6/36 bilaterally. Fundalexamination showed macular bicycle wheel appea-rance with cystoids macular changes. Tentativediagnosis of juvenile retinoschisis was made. Opticalcoherence tomography (OCT) of macula revealed

1Senior Registrar,2Registrar, 3Post Graduate Trainee, 4Consultant Ophthalmologist Eye Unit, Sri JayawardenapuraGeneral Hospital, Kotte, Sri Lanka.

typical splitting of retinal nerve fibre layers. Fluorescienangiography showed window defects with no leaks.Diagnosis of juvenile retinoschisis was made. At sixmonths follow up repeat OCT macula showed nosignificant progression.

Discussion and conclusions

The natural history of juvenile retinoschisis, whereprogressive loss of vision in the 1st and 2nd decadesof life is followed by next phase of relative stabilityuntil the 5th decade, where further deteriorationoccurs, needs to be explained to the patient. A positivefamily history would help in the diagnosis of juvenilex linked retinoschisis. OCT macula is useful todocument the progression of disease. Vitreous haemor-rhage, neovascularisation and retinal detachment areknown complications. The prognosis is poor due toprogressive maculopathy.

journal of the college of ophthalmologists of sri … · 2019. 8. 22. · journal of the college of...

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