kjo - ksos - kerala society of ophthalmic surgeons · kjo contents 397 pediatric cataract surgery...

C O N T E N T SKJOEDITORIAL

339 Waiting for ………………….. Robo 4: The Wonder Protein !!!

Dr. Meena Chakrabarti

MAJOR REVIEW

341 Current approach in diagnosis and management of scleritis

Dr. Zahadur Rahman, Dr. Jyothirmay Biswas

ORIGINAL ARTICLES

349 Natural history of Juxtafoveal Retinal Telangiectasia

Dr. Mahesh .G, Dr. A. Giridhar, Dr. Archis Shedbale,

Dr. Ram Kumar, Dr. Alpesh Rajput

355 Bevacizumab (Avastin) Therapy for macular oedema in

Central Retinal Vein Occlusion – Long term results

Dr. George J. Manayath

362 Ocular Ischemic Syndrome (OIS): A comparative analysis of

Management Options

Dr. Meena Chakrabarti, Dr. Valsa T.Stephen, Dr. Sonia Rani John

Dr. Arup Chakrabarti

367 Primary IVTA with secondary macular laser versus primary macular laser

with secondary IVTA in diabetic macular oedema with

subfoveal sensory detachment

Dr. Gopal S. Pillai, Dr. Niranjan

371 Long term results of surgical management of severe contusion injury

with dislocated lenses

Dr. Meena Chakrabarti, Dr. Valsa T. Stephen, Dr. Arup Chakrabarti,

Dr. Sonia Rani John

OCULAR PHARMACOLOGY

377 Intravitreal Bevacizumab

Dr. Sonia Rani John, Dr. Meena Chakrabarti, Dr. Valsa T. Stephen


OPHTHALMIC INSTRUMENTATION

382 High end phaco systems: A comparison

Dr. Ashley Thomas

385 Spectacles- what we do not know

Dr. Bindu N. Das

OPHTHALMIC SURGERY

392 Management of dislocated PC IOL

Dr. Meena Chakrabarti, Dr. Valsa T. Stephen, Dr. Sonia Rani John


C O N T E N T SKJO397 Pediatric cataract surgery

Dr. Rupal H. Trivedi, Dr. M. Edward Wilson

CURRENT CONCEPTS

408 Investigations in microbial keratitis

Dr. Jyothi P.T.

412 Parasitic keratitis

Dr. Ranjakumar

COMMUNITY OPHTHALMOLOGY

417 ‘’Less than perfect outcomes’’ after an uneventful cataract surgery

Dr. Meena Chakrabarti, Dr. Valsa T. Stephen, Dr. Sonia Rani John,


CASE REPORT

419 Ocular contusion injury due to pelting with hard boiled eggs

Dr. Meena Chakrabarti, Dr. Valsa T. Stephen, Dr. Sonia Rani John,


421 Lacrimal canaliculitis - A case report

Dr. Bindu N. Das, Dr. Sisira

423 Rips after pricks - A case series

Dr. Mahesh G., Dr. A. Giridhar, Dr. Siddarth Pawar, Dr. Ramkumar,

Dr. Alpesh Rajput

425 Combined cilioretinal artery occlusion and

Central Retinal Vein Occlusion - A case report

Dr. Valsa T. Stephen, Dr. Sonia Rani John, Dr. Meena Chakrabarti


PHOTOESSAY

427 Leber’s Multiple Miliary Aneurysm

Dr. Valsa T. Stephen, Dr. Sonia Rani John, Dr. Meena Chakrabarti,


430 CONSULTATION SECTION

434 OPTHALMIC HISTORY

437 JOURNAL REVIEW

440 BOOK REVIEW

445 UPCOMING CME

447 PG TEAR SHEET

451 INSTRUCTIONS TO AUTHORS

EDITORIAL

Waiting for ………Robo 4:

The Wonder Protein!!!

Recent research has shown that Robo 4 may unlock cures for blinding conditions such

as age related macular degeneration (AMD) and Proliferative Diabetic Retinopathy

(PDR). Robo 4, an endogenous protein also called Roundabout gene is a protein that

sits on the surface of cells in the blood vessels and essentially Robo 4 acts to stabilize

the blood vessels.

Blood vessel growth (Angiogenesis) is critical in human development and represents

the body’s natural response to injury or inflammation. Earlier research by Li et al have

conclusively shown that a family of proteins, netrins, induce blood vessel and nerve

growth in mice, a discovery that had great impact for development of potential therapies

to help people with too few blood vessels.

In response to injury or disease, new vessel growth occurs at the wrong place and at

the wrong time. These new vessels are usually very fragile with weak vessel walls

exhibiting a tendency to leak fluid into the surrounding tissues. Everything in biology

has a Yin (negative) to a yang (Positive). In the signaling pathway that induces new

vessels to grow, Robo 4 is the Yin to the yang of netrins. Cloned Robo 4 has been

shown to produce the opposite function of netrins by inhibiting angiogenesis and

stabilizing the walls of blood vessels preventing leakage. Robo 4 is found only in cells

in the interior surface of blood vessels and is activated by a protein called Slit. After

being activated, Robo 4 initiates a chain of biochemical events to stabilize blood vessel

and prevent uncontrolled growth.

Many diseases are caused by injury or inflammation destabilizing the blood vessels

and causing leakage of fluid into the adjacent areas. The Robo 4 pathway is a natural

pathway that acts like an endogenous brake stabilizing the blood vessels. When the

accelerators act (like VEGF) to induce migration, tube formation and permeability of

the capillaries – Robo 4 chips in as an armored brake inhibiting the action of VEGF.

The researchers from the University of Utah tested the power of Robo 4 in mice eyes

because they are very similar to human eyes. They successfully demonstrated that

Robo 4 activation curbed new vessel development.

It is the theorized that some type of of gene therapy involving Robo 4 could be

prescribed for humans at risk for either AMD or PDR – perhaps an injection or an eye

drop. Lengthy clinical studies are underway, and their results alone will prove whether

340 Kerala Journal of Ophthalmology Vol. XX, No. 4

Robo 4 is safe and efficacious for human use. Hence a waiting period of several years

is anticipated before Robo 4 is available for use in AMD and PDR patients. If the study

results prove what has been predicted we can look forward to the dawn of a future

filled with hope.

Dr. Meena Chakrabarti MS DO DNB

Editor

December 2008 Z Rahman et al. - Scleritis 341

M A J O RR E V I EW

Current Approach in Diagnosis and

Management of ScleritisDr. Zahedur Rahman MS, Dr. Jyotirmay Biswas MS

Introduction

Scleritis is a chronic, painful, and potentially blinding

inflammatory disease that is characterized by

edema and cellular infiltration of the scleral and

episcleral tissues. Because of the potentially devastating

ocular complications and possible association with

serious systemic disease, the diagnosis of scleritis

should not be missed. Scleritis most often presents

within 4th–6th decades with a mild preponderance

towards women over men (1.6:1) 1,2,3. Scleritis is

usually suspected from clinical history, and it is

confirmed by its characteristic clinical signs. In a case

of posterior scleritis, ultrasonography and other imaging

studies may be necessary to confirm the diagnosis.

Anatomic considerations

The function of the sclera is to provide a firm protective

coat for the intraocular contents. This coat is resilient

enough to allow for variations in the intraocular

pressure, firm enough to prevent severe distortion of

the contents of the eye on movement or when pressed

on by the muscles or external forces.

The bulbar conjunctiva is a thin transparent mucous

membrane, the epithelium of which is continuous with

the corneal epithelium. Beneath the epithelium lies

stroma which is a loosely arranged connective tissue.

Tenon’s capsule is a dense well defined membrane

which extends backwards from the limbus to ensheath

the extraocular recti muscles and becomes continuous

with the perimysium. It also passes backwards to cover

the globe. Posteriorly it becomes inserted into the dural

sheath of the optic nerve.

The episclera forms the superficial aspect of the sclera.

It is a thin dense, vascularised layer of connective tissue,

the fibers of which are continuous with the underlying

sclera. The episclera is immobile, when viewed with a

slit-lamp microscope. Lamina fusca is the innermost

layer of the sclera adjacent to the uvea.

In order to reliably differentiate episcleritis and scleritis,

an understanding of the anatomy of the vascular

plexuses contained within the conjunctiva, episclera,

and sclera is essential.. The blood supply to this region

is enormous, being derived from the anterior ciliary

arteries, but with extensive collateral arterial

anastomoses to the posterior ciliary arteries at the root

of the iris . The anterior system is readily visible with

the slit lamp and by anterior segment fluorescein

angiography, especially if the eye is inflammed, and its

recognition is of vital importance in the differentiation

of episcleral and scleral conditions. The separation and

displacement of these vascular layers give the most

important clinical clues to the site and the severity of

the inflammation. On slit lamp examination, three

layers of vessels are readily visible. The conjunctival

plexus, which is the most superficial layer of vessels,

can be moved over the underlying structures. The

superficial episcleral capillary plexus is a radially

arranged series of vessels lying within the parietal layer

of Tenon’s capsule. The vessels in this layer anastomoseUvea department, Sankara Nethralaya, 18, College road, Chennai-600 006.


at the limbus with the conjunctival vessels, with other

members of the same plexus, and with the deep plexus.

The deep episcleral capillary network is closely applied

to the sclera in the visceral layer of Tenon’s capsule.

The conjunctival and superficial episcleral vessels can

be blanched with 1:1000 epinephrine or 10%

phenylephrine, but the deep vessels are affected slightly.

This is of considerable assistance when attempting to

differentiate deep and superficial scleral inflammation.

Classification

In 1976,Watson and Hayreh proposed a clinical

classification of scleritis based upon the anatomic

location of the inflammation and the observed

alterations in the associated vascular structures .This

categorization of disease entities does not infer etiology,

but provides valuable information regarding severity

of inflammation, prognosis, management options, and

association with systemic diseases and with ocular

complications. Few patients progress to a different form

of scleritis from their initial presentation.

Scleritis is defined as anterior or posterior based upon

the location of inflammation, relative to the equator of

the globe. The majority of scleritis is anterior and can

be categorized as non-necrotizing or necrotizing.

Diffuse and nodular scleritis are non- necrotizing and

represent the most common forms of anterior scleritis.

The necrotizing types of anterior scleritis are less

common ,but represent a more severe disease entity 1, 3.

Necrotizing scleritis is classified as either with

inflammation or without inflammation, with the latter

being synonymous with scleromalacia perforans.

Ultrasonographic classification categorizes posterior

scleritis as diffuse or nodular, based upon increased

eye wall thickness or finding of scleral nodule,

respectively.

Classification of scleritis

I. Anterior scleritis

a) Diffuse

b) Nodular

c) Necrotizing

i) With inflammation

ii) Without inflammation( scleromalacia perforans)

II. Posterior scleritis

a) Diffuse

b) Nodular

Scleritis may be classified etiologically, although it is

most often idiopathic or associated with a systemic

disease, scleritis can also be post surgical or related to

an infectious process. In one study, 25–57 % of scleritis

cases were associated with a known systemic

condition 1,2,3. In the Watson and Hayreh series,

connective tissue disorders were present in 15 % of

the patients, of which rheumatoid arthritis constituted

10 %. In another series with a higher proportion of

necrotizing scleritis cases, half of the patients had an

associated systemic connective tissue or vasculitic

disease 1. Necrotizing scleritis has the highest

association with systemic illness and represents the

most frequent type of scleritis that is the first

manifestation of a systemic condition 1,3. Approximately

two-thirds of patients with scleromalacia perforans have

an associated systemic condition 1, most commonly

longstanding rheumatoid arthritis (47 %) 3. Diffuse

scleritis appears to be the most benign form with the

lowest prevalence of associated systemic illness.

Systemic conditions associated with scleritis are shown

in table 1. Vasculitis is a proposed common factor in

the pathogenesis of both scleritis and the systemic

autoimmune disorders. Scleritis may occur following

ocular trauma . Surgically induced necrotizing scleritis

(SINS) can occur after any type of ocular surgery with

scleral manipulation, including cataract surgery,

strabismus surgery, filtering blebs, pterygium surgery,

and operations for retinal detachments. Many

organisms have been reported as possible causes of

scleritis and these are shown in table 2.

Table 1 Systemic diseases associated with scleritis

Rheumatoid arthritisWegener’s granulomatosisInflammatory bowel disease:Ulcerative colitis and Crohn’s diseaseRelapsing polychondritisSystemic lupus erythematosisPolyarteritis nodosaGiant cell arteritisBehçet’s diseasePolymyalgia rheumaticaReiter’s syndromeRaynaud’s diseaseIgA nephropathyAnkylosing spondylitis


GoutSarcoidosisRosaceaPsoriasisLymphoma (Hodgkin’s)Pyoderma gangrenosumCogan’s syndromeNecrobiotic xanthogranuloma

Table-2 Infectious scleritis

BacterialPseudomonasProteus mirabilisStaphylococcus epidermidisStreptococcus pneumoniae

ViralHerpes zosterHerpes simplexMumps

GranulomatousMycobacterium tuberculosisMycobacterium chelonaeMycobacterium lepraeSyphilis

FungalAspergillusPseudallescheria boydiiSporotrichosis

ParasiticAcanthamoebaToxocariasisToxoplasmosisOnchocerciasis

Histopathology

Previous pathologic studies were based upon tissue

obtained from enucleated eyes with advanced

disease 4. Scleral biopsies have rarely been performed

because of the high rate of associated complications.

The pathologic findings of scleritis are classified as

(1) rheumatoid and rheumatoid- like necrotizing

scleritis, (2) idiopathic necrotizing scleritis, (3) post

infectious scleral inflammation, and (4) sarcoidal

inflammation 5,6 .

The typical feature of rheumatoid or rheumatoid-like

scleritis is central scleral necrosis with a distinct

surrounding zone of granulomatous inflammation 5,6,7.

Inflammatory cell infiltration with polymorphonuclear

leukocytes, histiocytes, and lymphocytes within the

episcleral tissue and suprachoroidal area, the presence

of an associated necrotizing vasculitis, and scleral fibre

necrosis between the pars plana and limbus are other

notable findings in rheumatoid scleritis.

In scleritis following a previous herpes zoster

ophthalmicus infection, histologic findings usually

include scleral necrosis, an associated vasculitis, and

surrounding zonal granulomatous inflammation,

primarily in the anterior sclera 5,6. The inflammation

can be non-granulomatous and focal. Although the

scleritis is suspected to be an immune-mediated

response to the prior infection, the presence of a reactive

proliferation of granulation tissue distinguishes this

form from the rheumatoid type. In infectious scleritis,

the presence of microabscesses with or without

histologic identification of a pathogen can be a

distinguishing factor.

Idiopathic necrotizing scleritis is characterized by

chronic, non-granulomatous inflammation and

diffuse lymphocytic infiltration of the anterior sclera,

episclera, and uvea 5,6 The presence of newly formed

vascular channels and focal granulation tissue with

fibroblasts, lymphocytes, and histiocytes in idiopathic

scleritis may be suggestive of a delayed type of

hypersensitivity 8.

Clinical Presentation of Scleritis

The clinical presentation of scleritis depends upon

the anatomic site involved and extent of inflammation.

The characteristic feature of scleritis is the severe

pain that may involve the eye and orbit and radiates

to involve the ear, scalp, face, and jaw. Scleritic pain

is typically dull and boring in nature, exacerbated

by eye movement. It is worse at night often interfering

with sleep, and characteristically wakens the

patient from sleep early in the morning. The pain is

usually severe in nature and resistant to mild

analgesic.

Scleritis typically has a gradual onset of redness with

increasing inflammation over several days 3. In contrast

to the brighter redness of episcleritis, scleritis is usually

a darker violaceous-red hue due to the depth of the

congested vascular plexus.

The patient with anterior scleritis usually notices

redness and tenderness of the globe. There may be

photophobia and lacrimation. Patient with posterior

scleritis may present with reduced vision with or

without pain. Patients may have features of an

underlying systemic disorder.


Physical examination: ocular signs

The key clinical observations in patients with scleral

inflammation involve determining the relationship of

the vascular plexuses to each other and the site of

maximum vascular involvement best seen with red-free

light on slit- lamp biomicroscope. Deep discoloration,

extent of scleral edema, and areas of increased

transparency are best appreciated in natural day light 3.

A hallmark finding that distinguishes scleritis from

episcleritis is the presence of scleral edema. Edematous

sclera can bow forward, displacing the deep episcleral

vascular plexus and exacerbating deep vascular

congestion. To assess the degree of scleral involvement,

blanching the superficial conjunctival and episcleral

vasculature with topical 10 % phenylephrine can

improve visualization of the underlying tissue. Further

examination using a red-free filter is instrumental in

evaluating the vascular architecture, areas of

avascularity, and cellular infiltration of the episclera.

The anatomic location of the inflammation and typical

alterations in the vessels form the basis of the

classification of the vascular layers overlying the nodule

are displaced forward 3.

Diffuse anterior scleritis: It is the most benign and

most common form of scleritis characterized by diffuse

involvement of anterior sclera by oedema and dilatation

of deep episcleral vascular plexus. These changes lead

to distortion of the normal vascular pattern which

remains as permanent marker of past scleral

inflammation. The swollen sclera loses its normal

appearance and takes on a dusky hue which is much

more obvious when viewed in daylight (Fig.1). The

globe is usually tender to touch.

nodules. Typically, the nodule is a darker hue of red,

separate from the overlying episclera, immobile, and

tender to palpation. These features distinguish this form

of scleritis from nodular episcleritis. The lack of necrosis

within the nodule and the containment of inflammation

within the borders of the nodules differentiate this form

from necrotizing anterior scleritis with inflammation.

All of the vascular layers overlying the nodule are

displaced forward (Fig. 2).

Fig1.Diffuse anterior scleritis

Fig 2. Nodular anterior scleritis

Necrotizing scleritis with inflammation:

Necrotizing scleritis, the most severe form of scleritis

is a serious threat to vision and integrity of the eye.

Aching pain, particularly in head, is usually the

predominant feature. The scleral involvement is

characterized by severe vasculitis and there are visible

areas of capillary non perfusion on clinical examination.

Ischemia subsequently leads to scleral infarction and

necrosis. The edges of the affected area is usually far

more inflammed than its centre where destructive

changes are occurring.

Thinning of the sclera with increased visualization of

the underlying uveal tissue may result in a bluish-grey

hue to the sclera. If any form of necrotizing scleritis

remains untreated then tissue loss occurs, producing

Fig. 3. Necrotizing scleritis with inflammation

Nodular anterior scleritis: Nodular anterior

scleritis can present with single or multiple scleral


overlying serous detachment of the neurosensory retina,

which represents the most common sign of posterior

scleritis 9, 10 . Ultrasound remains the key to diagnosis

with which the thickened posterior coat of the eye

(usually greater than 2 mm) can be identified (Fig. 5.)

Surgically induced necrotizing scleritis :

Surgically induced necrotizing scleritis (SINS) can occur

after any type of ocular surgery with scleral manipulation,

including cataract surgery, strabismus surgery, filtering

blebs, pterygium surgery, and operations for retinal

detachments 11,12,13,14. Inflammation is typically localized

to the site or adjacent to the site of surgery, but may

progress to involve the entire sclera 11,13 . Patients who

have SINS need careful systemic investigation as

62-90 % of patients in one study were later diagnosed

with autoimmune vasculitic disease which required

immunosuppessive therapy. 11,12,13

Investigations :

Because so many patients with scleral disease have

systemic disease, a thorough physical examination is

essential.

The following routine investigations should be

performed:

1. Hemoglobin

2. White blood cell count and differential count

3. Erythrocyte sedimentation rate

4. If connective tissue disease is suspected, full

immunologic investigations are undertaken, including

levels of immunoglobulins and immunofluorescent

studies for autoantibodies (including rheumatoid

factor and antinuclear and anti- ds- DNA antibodies);

circulating immune complexes are searched for.

If Wegener’s granulomatosis or polyarteritis nodosa

are suspected, the anti-nuclear cytoplasmic antibody

(ANCA) tests should be performed. The C-reactive

protein is the best indicator of an active generalized

inflammatory response.

5. Serum uric acid

6. Full serologic tests for syphilis

7. X-ray chest

B-scan ultrasonography should never be omitted from

the examination of patients with scleritis. Now that

high-quality ultrasonography has become available, the

milky white areas of necrotic sclera, episclera, and

conjunctiva. With time this dead tissue is absorbed,

leaving areas of dark choroid covered only by a thin

layer of atrophic conjunctiva (Fig. 3).

Scleromalacia perforans: Scleromalacia perforans

does not produce the acute signs of necrotizing scleritis,

may present with blurred vision from high astigmatism

due scleral thinning leading to loss of scleral rigidity.

The sclera may appear porcelain-like, as the vascularity

diminishes. Necrotic sclera can slough or become

sequestered. With severe scleral thinning, increased

visualization of the dark underlying uvea may occur.

Due to decreased scleral vascularity attributed to

arteriolar vaso-occlusion, large abnormal vessels

may cross and surround the areas of affected region

(Fig. 4).

Fig. 4. Scleromalacia Perforans

Posterior Scleritis: The presentation of posterior

scleritis depends upon the severity, extent, and location

of inflammation. The common signs of posterior scleritis

are posterior extension of anterior scleritis, a serous or

exudative retinal detachment, optic disc edema,

circumscribed subretinal mass, choroidal folds, retinal

striae, elevated intraocular pressure, and a bullous or

annular choroidal detachment 9. Extension of scleral

inflammation to the adjacent choroid can lead to an

Fig.5. Posterior scleritis


extent and severity of the inflammation can be

determined with great accuracy. Many patients who

were formerly thought to have only anterior segment

disease have been found to have extensive and sight-

threatening posterior scleritis as well. It also has become

known that many patients with posterior scleritis with

few symptoms and signs have much more extensive

disease than had previously been considered possible.

The hallmark features of posterior scleritis seen with

B-scan ultrasonography are helpful in differentiating

posterior scleritis from other conditions. B-scan

ultrasonography may reveal the characteristic flattening

of the posterior aspect of the globe due to retrobulbar

edema 15. Abnormally increased thickening of the

posterior ocular coats of the globe >2 mm, optic disc

swelling, distension of the optic nerve sheath, retinal

detachments, and choroidal detachments can be

detected. Fluid can accumulate in the posterior

episcleral space and extend around the optic nerve,

forming the characteristic “T-sign”on B-scan 9,15,16.

Ultrasound biomicroscopy :This can be valuable

for better delineation of scleral thinning and ruling out

any malignancy. An underlying squamous cell

carcinoma, medulloepithelioma can extend to the

sclera.

Complications of Scleritis :

Decreased visual acuity, keratitis, cataract, uveitis, and

glaucoma are ocular associations indicating the spread

of scleral inflammation to adjacent tissues 1,2,3 .

Complications are more frequent in severe necrotizing

scleritis and posterior scleritis 1,2,3. Due to potential

ocular complications related to scleritis, early diagnosis

and treatment of scleritis and its associated ocular

manifestations are critical.

Vision may be limited due to keratitis, anterior uveitis,

cataract, change of refractive status, macular oedema,

optic disc oedema, or atrophy, retinal detachment,

epiretinal membrane formation, macular cyst or hole, or

raised intraocular pressure. Decreased vision occurs most

frequently with posterior scleritis (45-84 %), necrotizing

scleritis (74-82 %), nodular scleritis (26 %) and least

often with diffuse anterior scleritis (9 %) 1,2

A mild to moderate anterior uveitis has been observed

in 30–42 % of patients with scleritis, most frequently

(69 %) with necrotizing scleritis 3,17. Almost half of the

patients with posterior scleritis have an anterior uveitis.

Corneal changes are most frequently seen in patients

with necrotizing scleritis including peripheral corneal

thinning, stromal keratitis, and peripheral ulcerative

keratitis 18. Patients with scleritis and keratopathy have

more chance of being associated with systemic diseases.

During any stage of scleral inflammation, the

intraocular pressure may be elevated due to several

different mechanisms, such as obstruction of the

aqueous outflow channels, elevated episcleral pressure,

angle closure, or secondary to a steroid response.

Cataract formation may be accelerated by long-standing

inflammation or secondary to steroid use. Scleral

thinning most commonly occurs in necrotizing scleritis

and may progress to staphyloma in the presence of

raised intraocular pressure.

Medical management:

The aim of treatment is to treat the cause, to control

the inflammatory process and thereby reduce the

damage to the eye. Treatment almost always requires

systemic therapy. Patients with an associated disease

need specific treatment.

� Treatment of noninfectious scleritis:

Nonsteroidal anti-inflammatory drugs (NSAIDs),

corticosteroids, or immunomodulatory drugs are

indicated. Topical therapy is routinely insufficient.

This treatment must be individualized for the

severity of the scleritis, response to treatment,

adverse effects, and presence of the associated

disease.

Diffuse scleritis or nodular scleritis:

� The initial therapy consists of an NSAID (eg:

Indomethacin 75mg twice daily after meal). In case

of therapeutic failure, 2 different NSAIDs should be

tried in succession with the first drug. In high-risk

patients, consider appropriate gastrointestinal

protection with misoprostol or omeprazole.

� If NSAIDs are not effective or have untoward

complications, oral corticosteroids (tab:

Prednisolone) at doses of 1 mg/ kg body weight

can be substituted. Remission may be maintained

with continued NSAIDs.


� Periorbital and subconjunctival steroid injections

(Inj.Triamcinolone acetonide 40 mg/ml) are

also effective in non-necrotizing anterior scleritis

(Fig. 6, Fig.7, Fig. 8). In case of therapeutic failure

of corticosteroids, immunosuppressive drugs

should be added or substituted. Methotrexate (initial

dose-15 mg/week and tapered monthly) can be the

first choice, but azathioprine, cyclophosphamide,

or cyclosporine may be helpful. Tumor necrosis

factor alpha (Tumour necrosis factor (TNF)-alpha)

inhibitor infliximab, may be effective, although

further investigation is warranted.

Necrotizing scleritis :

� Cyclophosphamide(100 mg per day orally and

tapered monthly) should be the first choice in

treating patients with associated potentially lethal

vasculitic diseases, such as Wegener’s granulomatosis

or polyarteritis nodosa.

� The initial therapy consists of immunosuppressive

drugs that are supplemented with corticosteroids

during the first month; the latter is tapered slowly,

if possible. Cyclophosphamide is the most effective

drug.

� In case of therapeutic failure, another

immunomodulatory drug, such as infliximab, may

be effective. Other alternatives are daclizumab and

rituximab, although their efficacy awaits further

study.

� Periocular steroid injections should be applied with

great caution in cases of necrotizing scleritis or

peripheral ulcerative keratitis. Some authors believe

that depot steroids actually may exacerbate

necrotizing disease or an underlying infection.

� Pulse intravenous cyclophosphamide with or

without pulse intravenous corticosteroids may be

required in case of emergencies and may be followed

by maintenance therapy.

Treatment of infectious scleritis: Systemic

treatment with or without topical antimicrobial therapy

always is required. Differentiating infectious scleritis

from non-infectious scleritis is important because

corticosteroid therapy and immunosuppressive therapy

(often used in noninfectious autoimmune scleritis) are

contraindicated in active infections.

Surgical care:

Tectonic surgical procedures rarely may be required to

preserve the integrity of the globe.

� Scleral grafts are fresh sclera or glycerin-preserved

sclera that is available through eye banks. Grafts

may be performed in cases of pending perforation

during the time before the effects of systemic

immunosuppressive agents manifest (Fig.9).

� Corneal tissue may be used for associated corneal

disease.

Fig. 6. Sub-conjuntival triamcinolone acetonide injection ina case of anterior scleritis

Fig. 7. Diffuse anterior scleritis before giving subtenoninjection of triamcinolone acetonide.

Fig. 8. Resolution of diffuse anterior scleritis two days aftergiving sub-conjunctival injection triamcinoloneacetonide.


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9. McClusky PJ, Watson PG, Lightman S. Posterior scleritis:clinical features, systemic associations, and outcomein a large series of patients. Ophthalmology. 1999; 106:2380–2386

10. Watson PG. The diagnosis and management of scleritis.Ophthalmology. 1980;87:716–720

11. Karia N, Doran J, Watson SL, et al. Surgically inducednecrotizing scleritis in a patient with ankylosingspondylitis. J Cataract Refract Surg.1999;25:597–600

12. O’Donoghue E, Lightman S, Tuft S, et al. Surgicallyinduced necrotizing sclerokeratitis (SINS) –precipitating factors and response to treatment. Br JOphthalmol.1992;76:17–21

13. Sainz de la Maza M, Foster CS. Necrotizing scleritisafter ocular surgery: a clinicopathologic study.Ophthalmology. 1991;98:1720–1726

14. Salamon SM, Mondino BJ, Zaidman GW. Peripheralcorneal ulcers, conjunctival ulcers, and scleritis aftercataract surgery. Am J Ophthalmol. 1982;93:334–33

15. Benson WE. Posterior scleritis. Surv Ophthalmol. 1988;32: 297–316

16. Biswas J, Mittal S, Ganesh SK, Shetty NS, Gopal L:Posterior scleritis: Clinical profile and imagingcharacteristics. Ind J ophthal 1998;46: 195-202

17. Sainz de la Maza M, Foster CS, Jabbur NS. Scleritis-associated uveitis. Ophthalmology.1997;104: 58–63

Sainz de la Maza M, Foster CS, Jabbur NS, Baltatzis S.Ocular characteristics and disease associations inscleritis-associated peripheral keratopathy. ArchOphthalmol. 2002 ;120:15-9.

Fig.9. Scleral patch graft

Consultations

� Rheumatology or internal medicine consultation for

associated disease

� Hematology, oncology, or internal medicine

consultation for immunosuppressive therapy

Conclusions

Scleritis is highly associated with potentially sight

threatening ocular complications and serious systemic

diseases. Early diagnosis and treatment of scleritis is

important in preventing and diminishing ocular and

systemic morbidity. Hence, attempts should be made

to achieve excellent long-term prognosis with careful

clinical history, detailed ocular examination, and use

of immunosuppressant drugs whenever necessary.

References

1. Sainz del la Maza M, Jabbur NS, Foster CS. Severity ofscleritis and episcleritis. Ophthalmology. 1994 ;101:389-96.

December 2008 Mahesh G. et al. - Juxtafoveal Retinal Telangiectasia 349

Natural History of Juxtafoveal Retinal

TelangiectasiaDr. Mahesh G FRCS Ed, Dr. A. Giridhar MS, Dr. Archis Shedbale MS, Dr. Ram Kumar DO, Dr. Alpesh Rajput DO

Idiopathic juxtafoveal retinal telangiectasia (IJRT) has

been considered a separate clinical entity since it was

first described by Gass in 1968 1. In 1993, Gass and

Blodi 2 examined 140 such cases seen at Bascom Palmer

Eye Institute, Miami over a 28-year period and

established a classification of these entities with

subgroups and stages. In recent years, newly recognized

manifestations have expanded and refined the clinical

spectrum of these macular vasculopathies. Furthermore,

the use of high-speed angiography and optical

coherence tomography (OCT) have provided a better

understanding of the nature of the vascular

abnormalities and their secondary effects in the macula,

to some degree paralleling histopathological

observations described in the ophthalmic literature 3-9.

There are few reports on the long term natural history

of IJRT 2,10,11.

We describe a retrospective series of 35 eyes of

20 patients with IJRT with special emphasis on visual

acuity.

Methods

We analyzed the case records of 35 eyes of 20 patients

diagnosed with IJRT between January 1, 1998 and

December 31, 2004. The standard for recruitment was

unilateral or bilateral presence of abnormal juxtafoveal

vessels documented by fundus fluorescein angiography

(FFA). At the follow-up visits, patients were questioned

about visual symptoms. Each patient underwent

complete ophthalmologic examination, including

biomicroscopy and indirect ophthalmoscopy. Colour

fundus photographs were taken during follow up visits.

Vision was assessed by using the standard eight steps

Snellen test charts; measurements were made on the

first and follow-up visits and recorded in the clinical

records. Comparative visual change between visits was

reported as lines of loss or gain. We assessed the clinical

photographic and fundus fluorescein angiography (FFA)

characteristics of eyes with type II A disease at first

visit and during follow-up using the stages of

development of parafoveal telangiectasis as described

by Gass and Blodi 3 : stage 1 is characterized by no

biomicroscopic abnormality, but staining and leakage

at the level of retinal pigment epithelium (RPE); Stage

2, by slight retinal graying and capillary telangiectasis

visible only by FFA; stage 3 by parafoveolar dilated and

right angled venules; stage 4 by RPE hyperplasia within

the retina; stage 5 by subretinal neovascularisation.

Results

There were 8(40 %) male and 12 female (60 %)

patients. Age in years ranged from 41 to 72 (Mean

49.65).Ten patients (50 %) were diabetic and

8(40 %) were hypertensive. Of the 20 study patients,

5 had Gass type IA disease and 15 had Gass type IIB

disease. Follow-up period varied from 4 months to 102

months (mean 35.6 months). Best corrected visual

acuity (BCVA) remained same in 16 eyes(45.71 %),

deteriorated by 1 or more lines in 11 eyes( 31.42 % ),

deteriorated by 3 or more lines in 3 eyes (8.57 %),

improved by 2 lines in 4 eyes (11.42 %), improved byGiridhar Eye Institute, Ponneth Temple Road, Kadavanthra, Cochin-682020,

Kerala. E-mail:[email protected]

ORIGINAL

A R T I C L E


1 line in 1 eye.(2.85 %). The cause for deterioration

included progression of IJRT in 9(64.28 %) eyes

,progression of cataract in 4 (28.57 %) eyes, branch

retinal vein occlusion (BRVO) in 1 (7.14 %)eye. Two

eyes showed improvement in BCVA as a result of

cataract surgery, 1 eye because of resolution of macular

edema, 2 eyes as a result of regression of corneal

disease. None of the eyes had diabetic retinopathy in

the beginning, but 6 eyes (15 %) developed changes of

mild NPDR and 4 eyes (10 %) moderate NPDR during

follow-up. None of these eyes had features of diabetic

macular edema/maculopathy

Type I B: Unilateral idiopathic, focal juxtafoveolar

telangiectasis

There were 5 patients (3 males and 2 females) who

had type I B disease. Mean age was 51.4 years. All these

patients had unilateral focal area of capillary

telangiectasis in the parafoveal area as evidenced by

fluorescein angiography. Of these 5 eyes, best corrected

visual acuity (BCVA) dropped by 1 line in 1 eye (20 %)

due to progression of IJRT, remained stable in 3 eyes

(60 %) one of which had poor vision due to BRVO,

which was confirmed by FFA (Patient 2; Table 1).BCVA

improved by 2 lines in 1 eye (20 %) as a result of

resolution of macular edema in eye(20 %) over a period

of 72 months follow-up (Patient 1; Table1)

Type IIA: Bilateral idiopathic acquired juxtafoveolar

telangiectasis

Thirty eyes of 15 patients were classified as having type

IIA disease. There were 5 male (33.33 %) and 10 female

patients (66.66 %) BCVA remained stable in 13 eyes

(43.33 %). BCVA dropped by 1 line in 7 eyes. (23.33%)

(all due to progression of IJRT).deteriorated by 2 lines

in 3 eyes (10%) (all due to progression of cataract),

deteriorated by 5 lines in 2 eyes (6.66%) (one due to

development of SRNVM and other due to BRVO).One

eye (3.33%) showed deterioration by 10 lines due to

progression of cataract to maturity. Three eyes (10%)

showed improvement in BCVA by 2 lines (2 eyes as a

result of cataract surgery and 1 eye because of

regression of corneal oedema).BCVA improved by 1 line

in 1 eye (3.33%) due to regression of corneal problem.

Case 10 (Patient10, Table 1) exemplifies progression

of disease to subretinal neovascularisation. This patient

was a 43 years old woman who noted gradual loss of

central vision first in the right eye and then in the left

eye for 6 months. She was neither diabetic nor

hypertensive. She was examined in December 2000 and

BCVA was 6/36 in right eye and 6/12 in left eye.

Parafoveal whitening, RPE proliferation and

pigmentation temporal to fovea was seen in right eye.

Fluorescein angiography of right eye showed leakage

of dye. (Stage 4 disease) Left eye showed retinal graying

and dilated and blunted retinal venules. FFA confirmed

this and showed leakage. (Stage 3 disease) In September

2001, her vision was stable at 6/36 in right eye and

6/12 in the left eye. There was increased pigmentation

and proliferation in the right eye. FFA showed about

same amount of intraretinal leakage in both eyes. She

was not seen again until March 2007. Her BCVA had

dropped to 2/60 in right eye and was stable at 6/12 in

left eye. Fundus photograph of right eye (Fig. 1a)

showed a scarred CNVM (Stage 5 disease) which was

confirmed by FFA (Fig 1c). Left eye fundus photograph

(Fig 1b) showed no significant change and FFA

Fig. 1e. OCT showing scarredmembrane in righteye

Fig. 1f. OCT showingpseudocyst in left

eye

Fig. 1c. FFA of right eyeshowing a scarred

CNVM

Fig. 1d. FFA showingincreased intra-retinalleakage in the left eye

Fig. 1a. Fundus photograph ofright eye showing ascarred CNVM

Fig. 1b. Normal left eyefundus photograph


(Fig. 1d) showed increased intra-retinal leakage

(stage 3 disease). OCT examination (horizontal line

scan) at this visit showed a scarred membrane in right

eye (Fig 1e) and pseudocyst in left eye (Fig 1f).

Case 15 (Patient15, Table 1) is an example

highlighting the slow rate of progression of the disease.

This 52 years old man complained of defective vision

in both the eyes of 6 years duration. He was a known

diabetic. On examination in December 2003, he was

missing letters of the Snellen‘s chart in both eyes and

his BCVA was 6/ 12 in right eye and 6/18 in left eye.

Anterior segment examination revealed immature

senile cataract in both eyes. Colour fundus photograph

of both eyes (Fig. 2a, 2b) showed parafoveal retinal

graying and crystals and left eye in addition showed

RPE hyperplasia and pigmentation. FFA of both eyes

(fig. 2c, 2d) showed telangiectatic capillaries and late

intra-retinal leakage of dye in both eyes. He was

followed up and in July 2005, his BCVA was stable at

6/12 in right eye and 6/18 in left eye. Anterior segment

examination was almost unchanged .Colour fundus

photo of right eye showed parafoveal retinal graying

and crystals. Left eye colour fundus photograph was

significant for the increase in the pigmentation. In June

2007 he presented with drop in visual acuity, BCVA

being 6/24 in right eye and 6/36 in left eye. Anterior

segment examination revealed significant progression

of cataract in both eyes. On colour fundus photography

(Fig 2e, 2f), both eyes were status quo. FFA was

significant only for the increase in the intra-retinal

leakage of dye (Fig 2g, 2h).There was no evidence of

subretinal neovascularisation in either eye. The

deterioration of visual acuity was mainly due to

progression of cataract.

Case 20 (Patient 20, Table 1) is another example which

highlights the very slow progressive nature of the

disease. This patient was 44 years old woman who had

Fig. 2 (a. & b.) showing parafoveal retinal graying andcrystals in both eyes and RPE hyperplasia andpigmentation in the left eye

Fig. 2. (c & d) FFA of both eyes showing telangiectaticcapillaries and late intra-retinal leakage of dye in botheyes

Fig. 2 (e & f) status quo colour fundus photograph of both

eyes on review

Fig. 2 (g & h) increase in the intra-retinal leakage of dye inboth eyes

Fig. 3 (a & b) showing parafoveal graying with crystals in

both the eyes

(c) (d)

(a) (b)

(e) (f)

(g) (h)

Fig. 3c. FFA showing lateleakage of dye in theright eye

Fig. 3d. FFA showing minimal

leakage of dye in theleft eye

(a) (b)

(c) (d)


noted gradual loss of vision first in right eye and then

in left eye since 6 months. She was examined in

September 2004. BCVA was 6/18 in right eye and 6/6

in left eye. There was parafoveal graying along with

crystals in both the eyes. (Fig 3a and Fig 3b). On FFA,

there was late leakage of dye in right eye (Fig. 3c) and

minimal leakage in left eye (Fig. 3d). She was followed

up and during her last visit in March 2007; BCVA was

stable in both eyes, 6/18 in right eye and 6/6 in left

Table 1. Long-Term Follow-up of Patients With Juxtafoveal Retinal Telangiectasia

Patient Age Sex Eye(s) Vision at Fundus Gass Duration Vision at Fundus Change Miscellainvolved first visit findings type of follow-up follow-up findings in visual neous

(months) acuity (cause forchange in Vn)

1 50 M RE 18-Jun MA, ME I B 72 9-Jun MA 2 Resolution ofME

2 49 M LE Jun-60 MA, ME,HE I B 12 Jun-60 MA 0 BRVO3 49 F LE 18-Jun HE, Hm.,TV I B 24 24-Jun Hem.,TV -1 Progression

of IJRT4 52 M RE Jan-60 Pigm.,HE II A 4 Jan-60 Pigm,HE 0

LE 6-Jun Pigm.,HE 6-Jun Pigm.,HE 05 50 F RE Jun-36 Pigm,HE,Hm II A 102 Jun-36 Pigm, 0 Progression

of IJRTLE 12-Jun Pigm 18-Jun Pigm, -1

6 49 M LE 6-Jun MA I B 8 6-Jun MA 07 66 F RE 6-Jun MA II A 48 Jun-60 ST BRVO -5 BRVO, ME

LE 6-Jun MA 12-Jun MA -2 Progressionof IJRT

8 45 F RE 12-Jun Whitng II A 48 18-Jun Whitng,MA -1 Progressionof IJRTProgressionof IJRT

LE 6-Jun Whitng 6-Jun Whitng,MA -1

9 57 F LE Jun-36 HE, Hm I B 36 Jun-36 HE 010 43 F RE Jun-36 Pigm II A 72 Feb-60 Scarred CNVM -5 Progression

of IJRTCrystals

LE 12-Jun Pigm 12-Jun 011 44 M RE 18-Jun Hm II A 12 9-Jun Whitng 2 Regression of

cornea

guttata in BELE 9-Jun Whitng 6-Jun Whitng 1

12 72 M RE Jun-36 Pigm., II A 42 Jun-36 Pigm., 0

LE 6-Jun Pigm 6-Jun Pigm -1 Progressionof IJRT

13 53 M RE 9-Jun Whitng II A 4 9-Jun Whitng 0 Progressionof IJRT

LE 6-Jun Whitng 9-Jun TV -114 57 F RE 18-Jun Whitng II A 30 18-Jun Whitng 0

LE 6-Jun Whitng 6-Jun Whitng 0

15 52 M RE 12-Jun Crystals II A 48 24-Jun Crystals,TV -2 ProgressionLE 18-Jun Crystals Jun-36 Crystals,TV -2 of Cataract in

BE

Fig. 3 (e & f) status quo fundus photograph in both eyes on

review

(e) (f)


16 58 F RE 24-Jun ME,Crystals, II A 24 18-Jun ME,Crystals, -1 Progressionof IJRT

Piigm Piigm MSCLE 9-Jun ME,Crystals, Jan-60 -10

Piigm17 61 F RE 12-Jun Whitng II A 6 12-Jun Whitng 0 Progression

of IJRTLE 9-Jun Whitng 9-Jun Whitng -1

18 50 F RE 24-Jun Crystals, Whitng II A 12 9-Jun TV, Crystals 2Cataractsurgery in BE

Whitng 2LE 24-Jun 9-Jun Whitng

19 41 F RE 12-Jun TV II A 72 12-Jun TV,Crystals 0LE 9-Jun TV 9-Jun TV 0

20 44 F RE 18-Jun Whitng II A 36 18-Jun Whitng 0

LE 6-Jun Whitng 6-Jun Whitng 0

Pigm : Pigmentation, MA : Microaneurysm, ME: Macular oedema, Whitng: Whitening TV: Telangiectatic vessels, Hm : Haemorrhage,BRVO: Branch retinal vein occlusion. CNVM: Choroidal neovascular membrane, RE : Right eye, LE : Left eye, BE: Both eyes Vn:Vision

eye. Colour fundus photography showed the disease

to be status quo in both eyes. (Fig. 3e & 3f)

Discussion

There were 5(25 %) patients with type 1B disease and

15(75 %) patients with type 2A disease confirming that

type 2a is the most common form of IJRT 12. Majority

(16 eyes, 45.71 %) maintained a stable visual acuity

and vision loss in patients with IJRT is generally mild

and occurs over many years 11.

When we analyzed each disease type, there were

5 patients with type I B disease, of which majority

(60 %) were male and mean age was 51.4 years. This

pattern in which middle-aged men are most commonly

affected correlates well with the demographic

characteristics described earlier 2,11. Regarding type 2A

disease, there were 15 patients and majority was

female. (66.66 %). This slight female preponderance

was in contrast to an earlier report 13 of equal sex

distribution.

Among the eyes in our study that lost vision, progression

of IJRT was responsible only in 64.28 % of cases. Loss

of central vision occurs slowly over many years and is

associated with atrophy of the foveolar retina 12. Visual

disturbance in retinal telangiectasia is usually due to

vascular leakage, with intra-retinal edema and exudate

accumulation and later cystic degeneration 13. However,

the development of neovascular membrane in the

vicinity of a black hyperplastic retinal pigment epithelial

plaque or a dilated vein passing at right angles into the

depth of the retina and indicative of a retinochoroidal

anastomosis can lead to rapid and severe visual

loss 2,14,15. None of the patients in our series developed

macular hole. The two recent reports 16,17 of full

thickness macular hole development in IJRT have

opened up a new dimension in the pathogenesis and

natural history of IJRT. The pronounced central foveal

structural abnormalities (for excavitation) could be due

to loss of the structural aspects afforded by Muller cells,

particularly the Muller cell cone. Hence loss of Muller

cells could be an important factor in the pathogenesis

of IJRT 17.

No intervention was done in any of the patients in our

series. Park and associates 16 attempted grid laser

photocoagulation for macular edema in IJRT but found

that it neither improved nor stabilized long-term visual

acuity. The role of any intervention arises only in

type 2 stage 5 diseases when there is development of

subretinal neovascularisation. Intravitreal injection of

triamcinolone acetonide has been found to be of some

benefit in few reports, but there are no randomized

controlled trials. The potential role of photodynamic

therapy with Verteporfin in IJRT with subretinal

neovascularisation has been well substantiated in

literature22-25. IJRT is a slowly progressive disease and

visual acuity remains stable for quite a long time.


Conclusion

IJRT has favourable prognosis unless there is

development of subretinal neovascular membrane 12.

References

1) Gass JD. A fluorescein angiographic study of macular

dysfunction secondary to retinal vascular disease. V.

Retinal telangiectasis. Arch Ophthalmol. 1968 Nov;

80(5):592-605.

2) Gass JD, Blodi BA. Idiopathic juxtafoveolar retinal

telangiectasis. Update of classification and follow-up

study. Ophthalmology. 1993 Oct;100(10):1536-46

3) Puliafito CA, Hee MR, Lin CP, et al. Imaging of maculardiseases with optical coherence tomography.Ophthalmology. 1995;102:217-229

4) Hee MR, Izatt JA, Swanson EA, et al. Optical coherencetomography of the human retina. Arch Ophthalmol.

1995;113:325-332.

5) Voo I, Mavrofrides EC, Puliafito CA. Clinical applicationsof optical coherence tomography for the diagnosis andmanagement of macular diseases. Ophthalmol Clin

North Am. 2004;17:21-31

6) Berger AS, McCuen BW II, Brown GC, Brownlow RL Jr.

Surgical removal of subfoveal neovascularization in

idiopathic juxtafoveolar retinal telangiectasis. Retina.

1997;17:94-98.

7) Davidorf FH, Pressman MD, Chambers RB. Juxtafoveal

telangiectasis: a name change? Retina. 2004;24:

474-478.

8) Green WR, Quigley HA, De la Cruz Z, Cohen B. Parafoveal

retinal telangiectasis: light and electron microscopy

study. Trans Ophthalmol Soc U K. 1980;100:162-170

9) Eliassi-Rad B, Green WR. Histopathologic study of

presumed parafoveal telangiectasis. Retina. 1999; 19:

332-335.

10) Watzke R C et al., Long-term juxtafoveal retinal

telangiectasia.Retina. 2005 Sep;25(6):727-35.

11) Gass JD, Owakara RT. Idiopathic juxtafoveolar

telangiectasis. Arch Ophthalmol 1982;100;769-780.

12) Engelbrecht NE, Aaberg TM Jr, Sung J, Lewis ML.

Neovascular membranes associated with idiopathic

juxtafoveolar telangiectasis. Arch Ophthalmol. 2002

Mar;120(3):320-4.

13) Albert DM and Jacobiec A. Principles and practiceof Ophthalmology. W B Saunders Co. 2000; 1957-1965

14) Gitter KA, Yannuzzi LA, Schatz H. The macula : acomprehensive text and atlas.Baltimore: Williams and

Williams,1979:118-26

15) Gass JDM. Retinal capillary diseases, In:.Stereoscopic

atlas of macular diseases. 4th ed. St. Louis;Mosby;

1997;504-12

16) Koizumi H, Slakter JS, Spaide RF.Full-thickness macular

hole formation in idiopathic parafoveal telangiectasis.

Retina. 2007 Apr-May;27(4):473-6

17) Olson JL, Mandava N.Macular hole formation associated

with idiopathic parafoveal telangiectasia. Graefes Arch

Clin Exp Ophthalmol. 2006 Mar;244(3):411-2

18) Park DW, Schatz H, McDonald HR, Johnson RN.Grid

laser photocoagulation for macular edema in bilateral

juxtafoveal telangiectasis. Ophthalmology. 1997 Nov;

104(11):1838-46.

19) Maia Junior OO, Takahashi WY, Bonanomi MT,

Nascimento VP, Melo CS.Intravitreal triamcinolone

injection in the treatment of idiopathic juxtafoveal

telangiectasis] Arq Bras Oftalmol. 2006 Nov-Dec; 69(6):

941-4

20) Li KK, Goh TY, Parsons H, Chan WM, Lam DS.Use of

intravitreal triamcinolone acetonide injection in

unilateral idiopathic juxtafoveal telangiectasis.Clin

Experiment Ophthalmol. 2005 Oct;33(5):542-4.

21) Cakir M, Kapran Z, Basar D, Utine CA, Eroglu F, Perente

I.Optical coherence tomography evaluation of macular

edema after intravitreal triamcinolone acetonide in

patients with parafoveal telangiectasis. Eur J

Ophthalmol. 2006 Sep-Oct;16(5):711-7.

22) Alldredge CD, Garretson BR. Intravitreal triamcinolone

for the treatment of idiopathic juxtafoveal telangiectasis.

Retina. 2003 Feb; 23(1):113-6.

23) Snyers B, Verougstraete C, Postelmans L, Leys A,

Hykin P. Photodynamic therapy of subfoveal neovascular

membrane in type 2A idiopathic juxtafoveolar retinal

telangiectasis. Am J Ophthalmol. 2004 May;137(5):

812-9

24) Potter MJ, Szabo SM, Sarraf D, Michels R, Schmidt-Erfurth

U.Photodynamic therapy for subretinal neovascularization

in type 2A idiopathic juxtafoveolar telangiectasis. Can

J Ophthalmol. 2006 Feb;41(1): 34-7.

25) Hershberger VS, Hutchins RK, Laber PW.Photodynamic

therapy with verteporfin for subretinal

neovascularization secondary to bilateral idiopathic

acquired juxtafoveolar telangiectasis. Ophthalmic Surg

Lasers Imaging. 2003 Jul-Aug;34(4):318-20.

26) Hussain N, Das T, Sumasri K, Ram LS.Bilateral

sequential photodynamic therapy for sub-retinal

neovascularization with type 2A parafoveal telangiectasis.

Am J Ophthalmol. 2005 Aug;140(2): 333-5.

27) Abujamra S et al., Idiopathic juxtafoveolar retinal

telangiectasis: clinical pattern in 19 cases.

Ophthalmologica. 2000;214(6):406-11.

December 2008 G.J. Manayath - Avastin in CRVO 355

Bevacizumab (Avastin) Therapy for Macular

Oedema in Central Retinal Vein Occlusion –

Long Term ResultsDr. George J Manayath MS

Introduction

Although central retinal vein occlusion (CRVO) is one

of the most frequent retinal vascular disorders in clinical

practice, its pathogenesis is still not fully understood.

Green et al. 1 found venous thrombi in nearly all

rubeotic eyes after CRVO, but it remains unclear

whether venous thrombus formation represents the

beginning or rather the endpoint of the pathogenetic

cascade.

The development of macular edema is one of the most

common findings and the main reason for decreased

visual acuity (VA) in early CRVO. An impaired

Abstract

Background: There is no proven treatment for vision loss in central retinal vein occlusion (CRVO).

Bevacizumab has been reported in small series with limited followup to have a positive effect in

reducing macular edema (CME) and improving vision in central retinal vein occlusion . We report

long term results of Bevacizumab in central retinal vein occlusion.

Methods: Prospective interventional case series included 15 patients, serially evaluated with ETDRS

BCVA, OCT, FFA and Tonometry. Results were statistically analysed.

Results: Mean followup was 12 +/-3.6 months (range 6 -18 months). Mean number of injections

2.2 (range 1- 4) per patient. Statistically significant reduction of macular thickness (P<0.001) was

seen at 6 weeks (mean 346μ), 3months (353μ), 6months (348μ) and final followup (342μ).

Significant BCVA improvement seen at 6 weeks (Mean - .27 logmar), 3 months (.3 logmar),

6 months (.15 logmar) and final followup (.21 logmar) (P=0.009). 73.3 % patients had > 2 lines

of BCVA improvement at last followup.

Conclusion: Intravitreal Bevacizumab is an effective treatment option for CME in CRVO patients.

Re-injections at appropriate timing based on the OCT findings are important for better visual outcome

microcirculation and reduced blood flow lead to a

dysfunction of the endothelial blood-retinal barrier with

increased permeability and plasma exudation into the

central retina. A causative therapy to normalize the

retinal perfusion is desirable, but only hemodilution

therapy has shown limited benefit in randomized

studies 2,3,4.

It seems reasonable to reduce the macular edema as

soon as possible as irreversible damage of the

photoreceptors occurs as early as 3 months after the

development of macular edema 5,6. GRID laser

photocoagulation is an evidence-based therapeutic

option to reduce the macular edema in patients with

branch retinal vein occlusion (BRVO), but not in centralChaithanya Eye Hospital, Kochi

ORIGINAL

A R T I C L E


retinal vein occlusion (CRVO) 7,8. Another option is the

injection of triamcinolone (IVTA) into the vitreous

cavity, which seems to be effective in early RVO.

However, recent results suggest that this effectiveness

is not maintained beyond 1 year despite repeated

injections. The main drawback of IVTA use is the high

rate of possible side effects such as glaucoma, cataract

formation or endophthalmitis 9,10,11,12. As in CRVO

patients the macular edema is thought to be at least

partly triggered by hypoxia-induced expression of

vascular endothelial growth factor (VEGF) 13,

intravitreally administered anti-VEGF antibodies have

recently been introduced into the treatment regime for

RVO patients 14.

Bevacizumab (Avastin, Genentech) was ,along with

pegaptanib,among the first anti-VEGF substances used

to treat macular edema in patients with CRVO 15,16,17.

Initial reports on intravitreal injections of bevacizumab

showed a significant reduction of central retinal

thickness and improved VA 14, 18. To date, only

retrospective studies and short term reports have been

published on bevacizumab treatment of CRVO 14, 18.

In this study we evaluate the safety,visual acuity changes

and morphologic response to bevacizumab treatment

in a prospective case series of CRVO patients.

Patients and Methods

Fifteen consecutive CRVO patients with central macular

oedema (CME) were included in this study.

Inclusion criteria

1. Funduscopically and angiographically diagnosed

CRVO duration of more than 4 weeks with CME of

more than 250 μm (measured by OCT 3, macular

thickness program).

2. Best corrected VA by ETDRS equal to or worse than

0.3 Logmar (Snellen = 6/12)

3. Age older than 18 years

4. Patient able to give informed consent

Exclusion criteria

1. Patients with retinal, angle or disc neovascularization

needing photocoagulation at first presentation

2. Other eye diseases that reduced VA

3. Not able to give informed consent

4. History of allergic reaction to bevacizumab

5. Pregnancy

6. History of Stroke/IHD/ uncontrolled HT

Study endpoints

The primary outcome was the improvement in visual

acuity (VA). Baseline visual acuity was measured using

ETDRS charts a few hours prior to injection as well as

on each follow-up visit (1 week and then 6 weekly after

injection). For ease of comparison and purpose of

statistical analysis, VA was converted to logMAR as well

as Snellen equivalents.

Secondary study outcomes were:

1. Central retinal thickness measured by optical

coherence tomography (OCT 3; macular thickness

program)

2. Complication rate (i.e., endophthalmitis, inflammation,

increased intraocular pressure, retinal tears, retinal

detachment and thromboembolic events)

3. To determine the best time point for re-injection

depending on the course of VA development as well

as central retinal thickness.

Patient examinations

The following data were registered: duration of CRVO

before injection, ophthalmologic and medical history,

patient age and sex, best corrected visual acuity (ETDRS

charts) and full ocular examination including OCT and

Applanation tonometry. We also documented retinal

changes by color fundus photographs and fluorescein

angiography (Topcon Imagenet, Japan) preoperatively

and between 6 and 12 weekly after injection.

All other parameters were evaluated on the day of

injection (baseline) as well as at 2 weeks and 6 weekly

after injection. On each follow-up visit, possible side

effects of the injection were ruled out.

Methods

All patients underwent intravitreal injection of 1.25 mg

bevacizumab (Avastin) in 0.05 ml total volume over


the inferior pars plana area, under strict aseptic

precautions. After 6 weeks of follow-up time, re-

injection of 1.25 mg bevacizumab was considered

depending on the individual treatment response and

OCT findings.

Study design

Our study design is that of a nonrandomized

interventional case series. All patients gave their

informed consent with specific emphasis on the off-

label character and possible systemic side effects as well

as unknown long-term ocular complications of

bevacizumab.

Statistics

Wilcoxon Signed Ranks test was used to calculate the

statistical significant difference between the paired

groups. Mann Whitney-U Test was used to calculate

the statistical significant difference between the two

independent groups. Friedman Multiple comparison

test was used to calculate the overall significance. The

level of significance was 0.05 (2-sided) in all statistical

testing. All these Statistical Analysis was performed

using the statistical software Stata 8.1 (College Station,

TX, USA).

Results

Table 1 displays the demographic data for all patients

enrolled in this study.

Table 1 Demographic data

No: of patients 15

Mean Age 64 years (40-82yrs)

Sex 13 Male / 2 Female

Duration of CRVO 3.3 months (range 1-10)

Type of CRVO 11 NICRVO / 4 ICRVO

The mean follow up was 12.2 ± 3.6 months (range -

6months to 18 months). All patients except one had

completed atleast 3 months since the last injection.

The mean number of injections per patient was

2.2 ± 0.884 (range – 1 to 4 injections per patient).

Visual acuity changes

The mean best corrected visual acuity at base line was

0.9 ± 0.31 Logmar units. Statistically significant BCVA

improvement (P = 0.009) was seen at 6 weeks 0.63 ±

0.34 (Mean improvement 0.27 logmar), at 3 months

0.60 ± 0.32 (mean improvement 0.31 logmar), at

6 months 0.74 ± 0.43 (mean improvement 0.15

logmar) and final followup 0.68 ± 0.54 (mean

improvement 0.21 logmar).

Overall there was a statistically significant improvement

in BCVA over time (P - 0.009) -FRIEDMAN test.

73.3 % patients had 2 or more lines of visual acuity

improvement and 60 % patients had 3 or more lines of

improvement. Table 2 shows the visual acuity change

distribution among the study patients at the final

follow up.

Fig. 1. changes in visual acuity over the study period

Table 2: Final BCVA (in logmar)

Frequency Percent

>2 lines improvement 9 60.0<=2 lines imporvement 2 13.3Remained same 2 13.3

Worsened 2 13.3Total 15 100.00

Macular thickness reduction

The mean central macular thickness (OCT) at baseline

was 615.7 ± 158.2 microns. Statistically significant

reduction of macular thickness (P<0.001) was seen at

6 weeks 269 ± 105μ (mean improvement 346μ), at

3 months 262 ± 129μ (mean improvement 353μ), at

6 months 261 ± 142μ (mean improvement 348μ) and

at final followup 273 ± 149 (mean improvement 342μ).

Overall there is a statistically significant difference in

macular thickness (p<0.001) - Friedman Test

73.3 % patients had a central macular thickness (CMT)

less than or equal to 250 microns at final followup visit.


Table 3 shows the macular thickness distribution among

the study group at final followup.

There was no direct correlation found between macular

thickness reduction and BCVA improvement, as macular

macular thickness(CMT) reduction, throughout the

study period (Figure 3).

Subgroup analysis was done to assess if early injection

was associated with better final visual outcome and

patients injected before 12 weeks since the onset of

CRVO(Gp 1) was compared with those injected after

12 weeks (Gp2) of disease onset. However, early

injection group was not found to be significantly

associated with better final BCVA improvement

(P= 0.557). (Table 4)

Subgroup analysis was done to assess if ischemic (Gp1)

and non ischemic (Gp2) nature of the disease has

impact on visual outcome. Ischemic CRVO was

significantly associated with poor final visual acuity

outcome (P= 0.026) (Table 5).

No ocular complications were noted during the entire

study period including glaucoma, cataract,

endophthalmitis, vitreous haemorrage or retinal

detatchment. However, a 55year old patient reported

an episode of ischemic heart disease 3 weeks following

his first injection . He was a hypertensive on treatment

with single drug and no other systemic diseases. It is

unsure if this was a coincidence or complication.

Discussion

Although the exact pathological sequence of CRVO is

unknown, visual acuity seems to be not only dependent

on macular ischemia, but mainly on CME and

photoreceptor damage in the early period of the disease.

The aim in RVO treatment should therefore include

different therapeutical aspects: (1) causal therapy for

improved blood circulation and (2) prevention of

secondary changes such as CME and neovascular

complications. Besides hemodilution 2,3,4, additional

treatment options have been evaluated for the

improvement of blood circulation without conclusive

results so far.

With bevacizumab a new treatment option has been

introduced for early intervention against the formation

Fig. 2. Reduction in macular thickness over the study period

Table 3. Central macular thickness reduction in the studygroup at final followup

Final CMT

Frequency Percent

<=250 microns 11 73.3>250 microns 4 26.7

Total 15 100.0

thickness reduction was more pronounced, preceded

BCVA improvement and due to the multiple factors

determining the latter. However, there was a general

trend of BCVA improvement associated with central

Table 4. Duration of Disease vs final BCVA - (p. 0.557) - Mann - Whitney U Test

Duration of Disease N Minimum Maximum Mean Std. Deviation

12 weeks Final BCVA (in logmar) 8 .00 2.00 .6500 .66117

12 weeks Final BCVA (in logmar) 7 .00 1.17 .7243 .50113

Fig. 3. Correlation of post injection best corrected visual

acuity (BCVA) and central macular thickness (CMT)


of CME. Although the intravitreal injection of bevacizumab

has already gained high clinical relevance for the

treatment of retinal vascular diseases, to date only few

short term studies have evaluated the course of CRVO

after bevacizumab treatment.One retrospective study

with 16 eyes found an improvement of visual acuity in

87.5 % of the eyes treated after 3 months 14 . A second

retrospective study with 15 eyes found an increase in

visual acuity of more than 3 lines in 40 % of the patients

treated 18. In a prospective study by Schaal et al with 6

months follow-up, 2.5 mg Bevacizumab was reported

to improve visual acuity in 73.3 % eyes with CRVO 19.

The present prospective case series of 15 patients with

CRVO evaluates the 1 year course of visual acuity and

central retinal thickness after bevacizumab injection.

Peak VA was reached between 3 and 6 weeks after

injection and ranged from 1 to 5 lines. Of the treated

patients, 60 % gained 3 or more lines. This number is

in line with published data from retrospective and

shorter term studies 14, 18,19,20. 73.3 % eyes resolved CME

at final follow up and maximum reduction of macular

thickness was achieved by 1-2 weeks following the

injection. Central macular thickness reduction preceded

improvement in BCVA. But, no direct correlation was

found between VA and CMT reduction.

Both patients with low as well as high baseline

VA benefited from bevacizumab injection. Patients with

good initial visual acuity showed a tendency to gain

1–2 lines, whereas majority of patients with moderate

visual loss (up to 6/60) gained more than 2 lines.

Stahl et al 20 in their prospective study reported

significantly better visual outcome in patients receiving

bevacizumab within first 3 months of onset of CRVO

compared to CRVO older than 4 months. However, in

the present study and in a recent prospective study by

Priglinger SG et al 21, no statistically significant

difference in the final visual outcome was found

between the early and late injection groups. This could

be due to multiple factors influencing the visual

outcome or a small sample size.

A subgroup analysis for different occlusion types

revealed less visual acuity improvement for Ischemic

CRVO patients compared to Non Ischaemic CRVO

patients. Only 1 of the 4 eyes of Ischemic CRVO had

3 line improvement, mainly due to macular ischaemia

or neovascular complications like vitreous haemorrage.

Three of the 4 ischaemic CRVO eyes developed

neovascularization and 2 eyes with non ischemic CRVO

had ischaemic conversion, while on treatment with

Bevacizumab. Therefore, the current dose of 1.25 mg

doesn’t prevent neovascular complications in CRVO.

Dose escalation studies like that of Costa et al 22 with

2mg bevacizumab in Ischemic CRVO also has not shown

improvement in the avascular or ischaemic status of

the retina and further dose escalation studies are

required to answer this issue. It must also be noted

that due to the small patient number, subgroup analyses

can only indicate tendencies and do not reflect

statistically significant results.

The improvement of visual acuity after bevacizumab

injection was concordant with a decrease in central

retinal thickness. Regular OCT examinations can thus

be regarded helpful for early detection of an impending

drop in visual acuity after bevacizumab injection. An

increase in central retinal thickness should be

interpreted as an indication for re-injection. Regarding

the number of re injections required to achieve a stable

condition,this study showed a mean of 2.2 injections

per patient (range 1- 4 injections) during the study

period. From the natural course of RVO, however, it is

known that the imbalance between inflow and outflow

of the retinal circulation can prevail for several months

or even years. The formation of a new blood flow

balance is presumably supported by the formation of

collateral disc vessels with a new drainage route 23. It

is likely that bevacizumab treatment must be upheld

until a new balance between inflow and outflow in the

retinal circulation is reached.

The main challenge in bevacizumab treatment is to

maintain patients within the initially reached range of

visual acuity by means of well-timed reinjections in

Table 5. Diagnosis Vs Final BCVA - (p-0.026) - Mann-Whitney U Test

Diagnosis N Minimum Maximum Mean Std. Deviation

ICRVO Final BCVA (in logmar) 4 .90 2.00 1.2675 .50089

NICRVO Final BCVA (in logmar) 11 .00 1.00 .4727 .44518


combination with laser treatment for the treatment of

secondary complications. Careful timing of bevacizumab

injection and laser treatment for ischemic complications

could have a beneficial effect.

The positive effect of bevacizumab injection on central

retinal thickness and visual acuity is evident when mean

values are considered, as was done in the present as

well as other studies 17, 19, 32. However, it should be

emphasized that within our study population some

individual treatment courses are not adequately reflected

by the presentation of the mean values discussed above.

Although most patients showed a good and reproducible

response to bevacizumab treatment, a certain inter

individual variability could be noted. In some patients,

a decrease of central retinal thickness was accompanied

by only a mild increase in visual acuity (due to macular

ischemia, foveal haemorrage with later

RPEdegeneration etc). In other patients, bevacizumab

injection neither diminished central retinal thickness,

nor improved visual acuity beyond week 3. These

patients did not differ from the rest of the study

population in terms of occlusion type, age of occlusion

or patient age. It can only be assumed that the degrees

of ischemia as well as other individual factors have an

impact on treatment response.

The causes and mechanisms for treatment failure with

bevacizumab injection have to be elucidated further in

vitro as well as in clinical studies. The question whether

bevacizumab might have negative long-term effects on

collateral vessel formation due to its anti-VEGF action

also needs to be addressed in these studies.

Conclusion

In summary, bevacizumab injection seems to

improve the visual acuity in the majority of CRVO

patients. This effect is probably due to a reduction of

blood vessel permeability similar to the effect of

intravitreally administered corticosteroids. In contrast

to intravitreal corticosteroids, however, a rise in

intraocular pressure was not observed in patients

treated with intravitreal bevacizumab. In the present

study, no other possible complications such as cataract,

pseudo-endophthalmitis, endophthalmitis, central

artery occlusion or retinal detachment were observed.

We therefore suggest bevacizumab treatment for

patients with CRVO under close postoperative

observation. Around week 6 after bevacizumab

treatment, re-injection should be considered based on

the OCT and visual acuity findings, until the disease

compensates.

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Ocular Ischemic Syndrome (OIS):

A Comparative Analysis of Management

OptionsDr. Meena Chakrabarti MS, Dr. Valsa Stephen MS, Dr. Sonia Rani John DNB, Dr. Arup Chakrabarti MS

The term ocular ischemic syndrome (OIS) includes a

constellation of ocular signs and symptoms secondary

to severe, chronic arterial hypoperfusion to the eye and

has been termed hypotensive retinopathy. The common

causes for ocular hypoperfusion include 1) ipsilateral/

bilateral carotid artery stenosis or occlusion 2) aortic

arch syndrome 3) giant cell arteritis and 4) ophthalmic

artery occlusion due to thromboembolism 1, 2.

This entity characteristically presents in individuals

between 50-80 years of age and shows a significant

male preponderance. Associated systemic diseases

include systemic arterial hypertension (73 %), diabetes

(56 %), ischemic heart disease (48 %), history of

previous stroke (27 %) and deep vein thrombosis or

thromboembolic episode. The classical triad of clinical

findings for the diagnosis of OIS includes fundus finding

of dilated nontortuous retinal vessels, mid peripheral

dot and blot haemorrhages associated with anterior

segment neovascularisation. The patient is symptomatic

with visual loss in 70 %-90 % and ocular pain (dull

aching or intractable pain) in 40 % of patients 3. Early

recognition of this entity is absolutely essential as it

may be the first manifestation of a carotid artery

disease. The disease is relentlessly progressive and

can lead to blindness (15 %), sudden cardiac deaths

(63 %) or a debilitating stroke (19 %).

A thorough systemic work up including the arm pulses,

cardiology and neurological work up is essential.

Estimation of ESR and CRP in all elderly patients will

help rule out giant cell arteritis. Imaging studies 4 such

as Carotid Doppler Imaging, Magnetic Resonance

Angiography may be necessary to confirm the diagnosis.

Symptomatic patients with recurrent non- disabling

strokes, hemispheric transient ischemic attacks and

amaurosis fugax who has 70 %- 99% carotid artery

stenosis will benefit from carotid endarterectomy. The

2 year ratio of stroke is reduced to 9 % in patients who

have undergone this procedure from the 26 % incidence

of stroke in patients who are on antiplatelets alone.

The treatment option for the ocular manifestation is

limited to panretinal photocoagulation with causes

regression of neovascularisation in 36 % of cases 5 in

early stages of the disease. As the diseases progress

and as more and more of the angle gets occluded the

success rate of PRP declines. Conservative management 6

in the form of medical control of intraocular pressure,

cyclodestructive procedures or glaucoma stents helps

alleviate symptoms. There have been recent reports of

the positive benefits of intravitreal injection of

Triamcinolone acetonide in causing resolution of

chronic cystoid macular oedema, and also on the

use of intravitreal bevacizumab either singly or

in combination with panretinal photocoagulation

in causing regression of anterior segment

neovascularisation and stabilizing the disease process 7.Chakrabarti Eye Care Centre, Kochulloor, Trivandrum 695 011

Email: [email protected]

ORIGINAL

A R T I C L E

December 2008 M. Chakrabarti et al. - OIS: Management options 363

There is no general consensus on the management of

the ocular manifestation in patients with OIS and hence

several modalities of treatment have been tried.

This paper investigates the clinical features, and

compares the results of various management options

in 25 patients with suspected ocular ischemic syndrome.

Materials and Methods

A retrospective case study in which 34 eyes of

25 patients were included in the study group if

they had at least three of the five inclusion criteria

[(a) asymmetric retinopathy (b) elderly patient with

NVI of unknown cause (c) asymptomatic anterior

uveitis in elderly (d) presence of dilated retinal vessels

with no tortuosity (e) presence of mid peripheral dot

and blot haemorrhages in an ischemic featureless

retina], necessary for a diagnosis of ocular ischemic

syndrome.

Patients with a diagnosis of ocular ischemic syndrome

underwent a detailed medical and ocular histories,

complete ophthalmic evaluation, carotid evaluation by

Doppler and a through cardiology and neurological

work up. The management options used and its

outcome were assessed and compared. The patients

were divided into two groups based on the treatment

options chosen 1) PRP alone, 2) Combination of PRP

and intravitreal Bevacizumab.

The outcome measures assessed included post

treatment visual acuity, variation in the intraocular

pressure, fluorescein angiographic findings and

complications. The patients were followed up at

monthly intervals for 12 months.

Results

We analyzed the clinical features and management options

in 34 eyes of 25 patients with a diagnosis of Ocular

Ischemic Syndrome. Analysis of the demographic data

showed that the patients were of age group ranging

from 60 years to 85 years (mean 63 ± 8 years). The

male female ratio in our study population was 2:1.

Associated systemic diseases included arterial

hypertension: 28.6 %, diabetes: 85.7 %, coronary artery

disease: 20 %, history of previous stroke: 30 % and

10 % of patients were on haemodialysis.

Thus in our study population, majority of the patients

had associated diabetes (85.7 %) and had presented

with features of both proliferative diabetic retinopathy

and chronic ocular ischemia out of proportion to the

retinal changes in the contralateral eye. The

presentation was unilateral in 64 % of patents while

bilateral involvement was seen in 36 %.

Presenting visual symptoms included gradual visual loss

in 82.5 %, sudden visual loss (17.5 %); dull aching

ocular pain in 30 % of patients. At initial presentation,

eyes with Ocular Ischemic Syndrome had a visual acuity

ranging from hand movements to 6/6. 50 % of patients

presented with a visual acuity of hand movements only.

Ophthalmic evaluation included slit lamp

biomicroscopy, applanation tonometry, fluorescein

fundus angiography, field charting and optical

coherence tomography. Results of ophthalmic

evaluation in our study population is listed in Table 1

Table 1: Ocular Findings in OIS

1 Corneal Oedema 5 %2 Hypotony 10 %3 Elevated IOP ( NVG ) 42 %4 NVI 88 %5 AS inflammation 20 %6 Cataract 30 %7 Optic Disc Pallor 30 %8 AION 10 %9 CRAO 12 %10 Combined OIS and DR 5.7 %11 Ischemic featureless retina 88 %12 Extensive CNP on FFA 40 %13 CME on OCT 10 %14 Classical triad of dot h/ages

in mid periphery, NVI and dilatednon tortuous veins 24 %

15 NVD and NVE 13 % and 8 %

NVG: Neovascular Glaucoma; NVI: Neovascularisation of Iris; IOP:Intraocular pressure; AS: Anterior segment; AION: Anterior IschemicOptic Neuropathy, CRAO : Central Retina Artery Occlusion, DR:Diabetic Retinopathy; CNP: Capillary Non perfusion, FFA: Fluorosceinangiography; CME: Cystoid Macular edema; OCT: Optical Coherence

Tomography

Corneal oedema was the presenting feature in 5 % of

our patients and these patients presented with visual

blurring and foreign body sensation as well as ocular

pain. Ocular hypotony was present in 10 % of patients

who had associated corneal striae, anterior chamber

inflammation and new vessels on the iris. Low arterial

pressure to the ciliary body with resultant decrease in

aqueous production is responsible for paradoxical

lowering of IOP in the presence of neovascularisation.


42 % presented with neovascular glaucoma out of the

88 % who had NVI at presentation. Anterior segment

inflammatory signs characterized by flare and cells in

the anterior chamber were present in 2 % of the study

population at initial presentation. Optic disc findings

included uniformly pale disc (30 %); anterior ischemic

optic neuropathy (10 %) and central retinal artery

occlusion (12 %). Majority of our patients (85.7 %)

were diabetic and presented with features of diabetic

retinopathy on an ischemic featureless background

associated with gross asymmetry in the fundus findings

between the 2 eyes. An ischemic featureless retina with

out much neovascular proliferation associated with mid

peripheral dot and blot haemorrhages, and venous

dilatation, as well as multiple intraretinal microvascular

anomalies (Fig. 1) was seen in 88 % of our patients

with suspected OIS. 40 % of patients had extensive

capillary non perfusion areas in the fluorescein

angiograms (Fig. 2). 10 % of patients had demonstrable

cystoid macular oedema in OCT images.

Neovascularisation of the disc was present in 13 % of

patients while only 8 % had neovascularisation

elsewhere in the retina. Carotid Doppler showed

significant occlusion due to atheromatous plaques in

40 % of patients. The degree of stenosis produced by

the plaques was less than 70 % on an average and hence

none of our patients where counseled to undergo

carotid endarterectomy.

A retrospective analysis of the treatment options and

the results were compared between the 2 treatment

groups. The post treatment visual acuity, intraocular

pressure, regression of NVI, need for repeat treatments

were compared in all three treatment groups. Table 2

gives a comparative analysis of results of treatment.

Table 2 Comparative Analysis of Treatment Options

Criteria PRP alone Combined(30 eyes) PRP with IVB

(4 eyes)

1 Post Rx BVCA Not affected Not affected2 IOP 7mm reduction 20 mm ±3 mm

at 3 months reduction at3 months

3 Regression of NVI + +++4 Time to regression 4 weeks 1 week5 Repeat Treatment Necessary in Not given

4 % for

recurrent VH

None of the treatment options produced any visual

improvement. Pan retinal photocoagulation was

effective in controlling the neovascular process in

36 % of the treated 30 patients. It had no effect on the

visual acuity and did not produce significant lowering

of IOP in patients with NVG (7 mm ± 2mm Hg).

Conservative treatment had to be continued along with

maximal anti glaucoma medication to keep the patient

Fig. 1. Classical clinical features of OIS in an unilateral caseshowing mid-peripheral dot and blot hemorrhagesand extensive capillary non perfusion in thefluorescein angiography

Fig. 2. Showing a featureless ischemic retina with extensiveCNP areas, NVI and macular ischemia

December 2008 M. Chakrabarti et al. - OIS: Management options 365

comfortable. PRP had to be repeated in 40 % of patients

for recurrent vitreous haemorrhage.

Combination of PRP with IVB was the treatment option

in 4 patients. This group had maximum reduction of

NVI, with regression occurring within 1 week. The IOP

dropped by 20 mm ± 8 mm Hg from the baseline.

Repeat treatment was not necessary. This combination

may prove valuable in patients who are detected early.

In addition to local treatment all patients continued

their regular medications for hypertension and diabetes

along with antiplatelet medications and were kept

under regular follow up with the cardiologist and

neurologist. In one patient there was progressive optic

disc pallor with decreased vision at 6 months following

IVB injection.

Discussion

We present a retrospective series of patients with ocular

ischemic syndrome. The characteristic features of our

series are

1. Early cases of OIS were included.

2. 87.5 % had associated diabetes and diabetic

retinopathy.

3. Carotid Doppler showed atheromatous plaque with

stenosis < 70 % in 40 % of patients.

4. 10 % of our patients presented with hypotony, NVI

and anterior segment reaction

5. 22 % of patients had acute visual loss either due to

AION (12 % ) or CRAO (10 % )

6. Aching orbital pain was present in 40 %

7. The incidence of NVG was 40 % in our series.

8. Ischemic featureless retina with mid peripheral dot

and blot haemorrhages was the commonest ocular

fundus finding.

9. Neovascular proliferation in the fundus was not

common with NVD in (13 %) and NVE in (8 %).

confirming with other series.

10. PRP as a treatment option was able to stabilize the

ischemic process in 36 % of patients. Recurrence

in the form of recurrent VH necessitated repeat

treatment in all patients in this group.

11. Combining IVB with PRP proved to be the most

efficacious treatment modality and should be

considered in all early cases with OIS.

12. Presence of NVI indicated as poor treatment out

come and hence early detection and initiation of

treatment is mandatory.

Thus eyes with asymmetric retinopathy with an

ischemic featureless background fundus appearance

will definitely benefit from combining IVB with PRP

especially if they also have diabetic retinopathy.

Conclusion

Early detection of features of OIS needs a high index

of suspicion 8. OIS should be suspected in the following

situations.

1. Elderly patients presenting with non specific and

asymptomatic anterior segment inflammation

2. Presence of asymmetric retinopathy

3. Presence of NVI of unknown cause in an elderly

patient.

4. Ocular hypotony in elderly in presence of NVI and

inflammation

5. Non tortuous dilation of retinal vessels.

6. Elderly patient with h/o non deblitating stroke,

transient ischemic attacks and amaurosis fugax

A thorough ophthalmic evaluation in addition to a

detailed systemic work up and imaging studies is

necessary in all patients. Control of systemic risk factors,

regular use of anti-platelet medication combined with

vigorous local treatment of the ocular condition, may

help safeguard the patient. Presence of iris

neovascualrisation heralds a point of no return

indicating progress of disease which will continue

unabated unless early intervention in the form of

combined PRP and IVB is given. Combining anti VEGF

therapy with PRP helps stabilize disease progression,

speeds control of anterior segment neovascualarisation

and eliminates need for subsequent surgeries.

Carotid Endarterectomy is necessary in symptomatic

patients with 70 - 99 % 9, 10 stenosis especially in the

presence of non disabling stroke, amaurosis and

hemispheric transient ischaemic attacks. Carotid


endarterectomy has been shown to reduce the 2 year

rate of stroke to 9 % in comparison to the 26 % incidence

in patients who are on anticoagulants alone. Bypass

procedures in the form of Superficial Temporal Artery

to Middle Cerebral Artery (STA-MCA by pass) can be

considered in patients with 100 % carotid stenosis.

5 % – 15 % of patients with carotid artery occlusive

disease develop ocular ischemic syndrome and this

condition can become bilateral in 20 % patients. Early

detection is mandatory to ward off permanent

blindness, debilitating stroke and sudden death.

Reference

1. Antebana N.H, Brown GC; et al. Ocular IschemicSyndrome, Duanes Clinical Ophthalmology, Ed.Tasman W, Jaeger EA, 1998, Vol:3, 12,1-19

2. Hamed L M, Guy JR, Moster ML, Bosely et al. Giant cellArteritis in Ocular Ischemic Syndrome. Am. J.Ophthalmol 1992, 113: 702-5

3. Johnson M A. Use of electroretinographic ratios inassessment of vascular occlusion and ischaemia,Principles and Practice of clinical electrophysiology of

vision Ed. Hickenlively J and Arden G, Ed by MosbyYear Book, 1991, 613-618

4. H O AC, Lieb WE, Flaharty PM et al. Color DopplerImaging of the ocular ischemic syndrome. Ophthalmol1992,99,1453-62

5. Mizeber JB, Podhajsky P, Hayreh SS. Ocular IscheamicSyndrome. Ophthalmology 1997;104:859-64

6. Ryan S J, Schachart AP, Murphy RP, Patz A. The OcularIschemic Syndrome. Retina, Vol II , Ed SJ Ryan; 1989;88; 547-59

7. Luis Amselemab, Javier Montero, Manual Daiz- Llopisb;S. Pulido et al. Intravitreal Bevacizumab injection inocular ischemic syndrome. Am J. Ophthalmol, 2007;Vol 144 (1): 122-124

8. Sivalingam A, Brown GC, Magargal LE. The OcularIschemic Syndrome III The visual Prognosis andthe effect of treatment. Intl. Ophthalmol 1991;15:15-20

9. Story JL, Held K, Harrison JM, Cleland TP, Eubanks KDet al. The Ocular Ischemic Syndrome in carotid arterydisease. Ophthalmic Color Doppler flow velocity andelectroretinographic changes following carotid arteryreconstruction. Surg Neurol 1995; 44:534-5

10. Winter Korn J M, Beckman RL et al. Recovery fromOcular Ischemic Syndrome after treatment withVerapamil J Neuro-Ophthalmol 1995;15:209-11

December 2008 Gopal S. Pillai et al. - IVTA and Macular Laser in DME 367

Primary IVTA with Secondary Macular Laser

versus Primary Macular Laser with

Secondary IVTA in Diabetic Macular Edema

with Subfoveal Sensory DetachmentDr Gopal S. Pillai MD DNB FICO FRCS, Dr Niranjan P. MBBS DNB

acetonide (IVTA) injection. There is continuing debate

about which treatment modality is superior.

In this study we tried to look at this subject in a selective

subset of diabetic macular edema patients having a

subfoveal sensory neural detachment (SFSND).

Methods:

No of patients: 22 consecutive patients

Inclusion criteria: Presence of diabetic maculopathy

irrespective of the status of diabetic retinopathy and

optical coherence tomography (OCT) showing

subfoveal sensorineural detachment.

Randomisation: Patients were randomly allocated

to one of the groups: one group receiving IVTA as

primary treatment and other group treated primarily

with focal macular laser.Dept. of Ophthalmology, Amrita Institute of Medical Sciences, Kochi

Abstract

22 eyes with subfoveal sensory detachment were randomized into primary IVTA and primary focal

macular laser and studied for 6 months

Macular thickness reduced and visual acuity increased significantly more in primary IVTA than in

primary laser after the first treatment. At the end of 6 months, there was still a statistically significant

difference between the two groups.

Primary IVTA gives better results in subfoveal sensory detachment than primary laser therapy.

Introduction

Nearly 171 million people worldwide have diabetes.

This figure is likely to double by 2030. India holds 31.7

million diabetic patients ranking first in the world. This

number is projected to increase to 79.4 million by 2030 1.

Diabetic Retinopathy (DR) is a common complication

of diabetes which accounted for 5 million blind in year

2002. 2 The increasing incidence of diabetes has caused

diabetic retinopathy to be included in the “priority list”

as a part of “Vision 2020” 2. Among the various types

of diabetic retinopathy, diabetic maculopathy is the

commonest cause of visual impairement 3.

The different modalities of treatment for diabetic

macular edema include focal macular laser

photocoagulation and intravitreal triamcinolone

ORIGINAL

A R T I C L E


Preoperative evaluation: Best corrected visual

acuity (BCVA) for distance and near, Fundus Fluorescein

Angiography (FFA), Optical Coherence Tomography

(OCT) of macula measuring central foveal thickness

and total macular volume.

Operative intervention:

IVTA: 4mg (0.1ml) triamcinolone acetonide injection

into vitreous cavity under all aseptic precautions in

inferotemporal quadrant 4mm from limbus in phakic

patients, 3mm in aphakes and 3.5mm in pseudophakes.

Patients were advised sitting up position for 24 after

injection.

Focal macular laser: No of burns: 200, strength of

burns: 150-200 mw, size of burns: 100-150 microns,

Site of burns: Leaking microaneurysms.

Post intervention follow-up: Schedules for next

day, after one week and then after one month and

6 months. At each visit BCVA for distance and near,

intraocular pressure and status of lens transparency

(especially in IVTA group), OCT of macula measuring

central foveal thickness and total macular volume was

obtained.

At the end of 1 month, if response to primary treatment

was not found to be adequate, either IVTA (for cases

who had focal macular laser as primary treatment) or

focal macular laser ((for cases who had IVTA as primary

treatment) was given.

Main outcome:

Improvement in best corrected visual acuity (BCVA)

for distance and near, central foveal thickness and total

macular volume.

Results:

Out of 22 patients, 12 were women and 10 were men.

The mean age was 63 years (range 49-70 years). All of

them were type II diabetics and 18 of them on insulin.

The average duration of diabetes was 20 years (range

5-29 years). 10 patients also had associated diabetic

nephropathy, 12 had hypetension and 8 had dyslipidemia.

During the course of study, these comorbidities were

monitored and were found to be stable.

The baseline mean foveal thickness in group I was

444.9 microns and 486.9 microns in group II.

The change in foveal thickness at the end of 1 month

and 6 months is shown in the following table 1.

Table 1: showing change in foveal thickness at 1 month and6 months

Mean foveal thickness Group I Group II

(microns)

Baseline 444.9 486.9

After I month 250.2 438.7

(Change) (-194.7) (-61.2)

After 6 months 212.6 312.6

(Change) (-241.7) (-177.5)

The drop in mean central foveal thickness was markedly

higher in group I than group II at the end of 1 month

and 6 months. This difference had strong statistical

significant (P < 0.005)

The baseline BCVA for distance and at I month & 6

month follow up is shown in following table 2.

Table 2: showing baseline BCVA at 1 month and 6 months

Mean BCVA for Group I Group IIdistance (in decimal)

Baseline 0.36 0.31

After I month 0.51 0.32

(Change) (+0.15) (+0.1)

After 6 months 0.62 0.44

(Change) (+0.26) (+0.13)

As seen from the above table, the improvement in

BCVA for distance is much more faster and better in

group I compared to group II. This is also statistically

significant. ( P < 0.05)

The near vision in both the groups had increased at 1

month and 6 months, the change between them was

not statistically significant.

IOP had risen from 2-8 mm of Hg in both the groups.

But there was no statistically significant rise at the end

of 6 months in either of the groups.

There was no significant cataract progression in either

of the groups till 6 months.

Discussion

Although several treatment modalities are currently

under investigation for diabetic macular oedema , the

only demonstrated means to reduce the risk of vision

loss from diabetic macular edema are laser

photocoagulation, as demonstrated by the ETDRS, and

December 2008 Gopal S. Pillai et al. - IVTA and Macular Laser in DME 369

intensive glycemic control, as demonstrated by the

Diabetes Control and Complications Trial (DCCT) 4 and

the United Kingdom Prospective Diabetes Study

(UKPDS) 5.

Recently, the managament of diabetic macular oedema

(DME) has significantly changed with the availability

of optical coherence tomography. It helps to classify the

DME in different types which guides the treatment 6.

We looked at the subset of patients who had a subfoveal

sensorineural detachment as shown by OCT. The reason

being these are the most visually significant cases and

we wanted to find out the best way of dealing with

these specific group of cases.

The frequency of an unsatisfactory outcome following

laser photocoagulation in some eyes with diabetic

macular edema has prompted interest in other

treatment modalities. One that has recently generated

interest is intravitreal injection of triamcinolone

acetonide.

How does IVTA act?: Diabetic macular edema results

from abnormal leakage of macromolecules, such as

lipoproteins, from retinal capillaries into the

extravascular space followed by an oncotic influx of

water into the extravascular space 7. The increase in

retinal capillary permeability and subsequent retinal

edema may be the result of a breakdown of the blood

retina barrier mediated in part by VEGF, a 45 kD

glycoprotein 8. The normal human retina contains little

or no VEGF; however, hypoxia causes upregulation of

VEGF production 9. So attenuation of the effects of

VEGF provides a rationale for treatment of macular

edema associated with diabetic retinopathy.

Corticosteroids, a class of substances with anti-

inflammatory properties, have been demonstrated to

inhibit the expression of the VEGF gene 10.

Intravitreal injection has been proposed as a way to

deliver corticosteroid (triamcinolone acetonide) to the

posterior segment. Triamcinolone acetonide is readily

available (Kenacort). However, it is not specifically

formulated for intraocular use. The most common dose

of triamcinolone acetonide used to treat eyes with

diabetic macular edema is 4mg 11. This dose is typically

used because at a shelf dosage of 40mg/cc, it is easily

aliquoted to a 4mg/0.1cc dose. A volume of 0.1cc is

readily injected into the vitreous cavity. Other than the

convenience of this dose, there are no data that support

the use of 4mg over any other alternative dose. The

use of 25mg of triamcinolone acetonide has less

commonly been used to treat eyes with diabetic macular

edema.12 However, there are no data that compare the

efficacy and safety of the 4mg vs. the 25mg dose.

Side effects of IVTA: Elevation of intraocular pressure,

progression of cataract and endophthalmitis are the

known side effects of this treatment.

Comparison of our results with other studies:

There was no study which compared the role of IVTA

and focal laser both in a specific population of patients

with subfoveal sensorineural detachment.

Kang SW & et al found that visual acuity and decrease

in foveal thickness was significantly better in patients

receiving IVTA followed by focal laser than patients who

receive only IVTA. 13

Our results were also similar.

We did not have any significant adverse effects apart

from transient elevation of IOP.

Shortcomings

Long term follow up data should be available to find

out the stability of these effects.

Conclusion

In cases of CSME with subfoveal sensorineural

detachment, first IVTA followed by focal macular laser

after a month gives significantly better outcome than

focal laser followed by IVTA.

References

1. “Diabetes Action now: An Initiative of the World Health

Organization & the International Diabetes Federation”

A WHO publication, 2004 pg: 10

2. “Blindness: vision 2020- control of major blinding

disease & disorders”, A WHO publication, Feb.2000.

3. ‘Retina’, Volume II Medical Retina, Editor in Chief:

Stephen Ryan, Fourth Edition, Elsevier Mosby publishers

2006, page no 1275.

4. Diabetes Control and Complication Trial Research

Group. The effect of intensive treatment of diabetes on

the development and progression of long-term

complications in insulin-dependent diabetes mellitus.

N Engl J Med 1993; 329:977-986.


5. UK Prospective Diabetes Study Group. Intensive blood-glucose control with sulphonylureas or insulincompared with conventional treatment and risk ofcomplications in patients with type 2 diabetes.UKPDS 33. Lancet 1998; 352:837-853

6. Atlas Optical Coherence Tomography of MacularDiseases, Vishali Gupta, Amod Gupta, Mangat Gupta,Jaypee brothers, First edition 2004.

7. Ferris F, Patz A. Macular edema: a complication ofdiabetic retinopathy. Surv 1640 Ophthalmol 1984; 28(suppl):452-61.

8. Aiello L, Bursell S, Clermont A, et al. Vascularendothelial growth factor-induced retinal permeabilityis mediated by protein kinase C in vivo and suppressedby an orally effective beta-isoform-selective inhibitor.Diabetes 1997; 46:1473-80.

9. Vinores S, Youssri A, Luna J, et al. Upregulation ofvascular endothelial growth factor in ischemic and

non-ischemic human and experimental retinal disease.Histol Histopathol 1997; 12:99-109.

10. Nauck M, Karakiulakis G, Perruchoud A,Papakonstantinou E, Roth M. Corticosteriods inhibit theexpression of the vascular endothelial growth factorgene in human vascular smooth muscle cells. Euro JPharmacol 1998; 341:309-15.

11. Martidis A, Duker J, Greenberg P, et al. Intravitrealtriamcinolone for refractory diabetic macular edema.Ophthalmology 2002; 109:920-7. 1696

12. Jonas J, Sofker A. Intraocular injection ofcrystalline cortisone as adjunctive treatment ofdiabetic macular edema. Am J Ophthalmol 2001;132:425-7.

13. Kang SW, Sa HS,Cho HY,Kim JI. Macular gridphotocoagulation after intravitreal triamcinoloneacetonide for diffuse diabetic macular edema. ArchOphthalmol. 2006 May;124(5):653-8.

December 2008 Kerala Journal of Ophthalmology 371

Long -Term Results of Surgical

Management of Severe Contusion Injury

With Dislocated LensesDr. Meena Chakrabarti MS, Dr. Valsa T.Stephen MS, Dr. Arup Chakrabarti MS, Dr. Sonia Rani John DNB

Introduction

Traumatic cataracts and subluxated or dislocated

crystalline lenses are frequently encountered in the

settings of severe ocular trauma. Traumatic cataracts

are thought to develop secondary to equatorial

expansion with rupture of the lens capsule. This

equatorial expansion may also cause a significant

amount of zonules to dehisce with subsequent

subluxation or dislocation 1. Dislocation implies a

complete displacement of the lens from the pupillary

region either posteriorly into the vitreous cavity or

anteriorly into the anterior chamber. Management of

these commonly encountered entities first requires a

thorough evaluation for any other associated pathology

such as herniation of vitreous into the anterior chamber,

angle recession, vitreous haemorrhage, retinal breaks

or retinal detachments 2.

History and Clinical Evaluation: - The evaluation of the

crystalline lens after injury requires a thorough

ophthalmic examination to look for an occult posterior

scleral perforation, vitreous herniation into anterior

chamber, gonioscopy for traumatic angle recession,

dilated indirect ophthalmoscopy for retinal tears, retinal

detachments or vitreous haemorrhage 3.

In the presence of traumatic hyphema or vitreous

haemorrhage, B. Scan ultra sonography 4 may be of a

great value in delineating the dislocated lens as well as

for evaluating for other associated posterior segment

pathologies.

We present the results of a retrospective analysis of 25

cases of severe contusion injury with dislocated

crystalline lenses, which was managed, at our centre

with lens removal and anterior chamber ACIOL

implantation.

Methods

A retrospective case sheet analysis of all cases managed

by us with a diagnosis of blunt injury severe enough to

cause dislocation of crystalline lens into the vitreous

cavity was performed. The data retrieved from the case

sheets included the mechanism of injury, the best

corrected visual acuity, biomicroscopic examination of

the anterior segment, tension applanation, associated

posterior segment findings, details of the surgical

procedure performed including the technique used for

lens removal and the type of IOL implanted, as well as

the intraoperative difficulties and post operative

complication both immediate and long term. The

duration of follow up was 24 months to 60 months.

All patients had undergone a thorough preoperative

evaluation, which included a detailed history to elicit

the mechanism of trauma, the time of presentation for

treatment and a thorough evaluation of both anterior

and posterior segment of the eye. The surgical

procedure depended on the results of the preoperative

evaluation. Patients with associated retinal detachment,Chakrabarti Eye Care Centre, Kochulloor, Trivandrum - 695 011,

E-mail: [email protected]

ORIGINAL

A R T I C L E


underwent a combined scleral buckling, pars plana

vitrectomy, use of perflurocarbon liquid to achieve

mechanical retinal flattering and also to elevate the

lens to the pupillary area. Lens removal was performed

using the ocutome cutter in 8 eyes, by using the

phacofragmatome hand piece in 9 eyes or though a

limbal incision in 9 eyes. In 22 of the 25 eyes an anterior

chamber Kelman multiflex AC IOL was implanted. In

three patients who had an associated retinal

detachment, underwent repair of the detachment along

with lens removal and were left aphakic. The presence

or absence of intraoperative problems, short and long

term postoperative complications were noted and

analyzed.

Results

A retrospective analysis of the case records of all

patients managed at our centre (between March 1999-

2007 March) for traumatic dislocation of crystalline

lens were analyzed. 25 patients with a postoperative

follow up varying from 24 months to 60 months formed

the study group (Mean 42 m).

The patients were of the age group 30-70 years of age

(Mean age = 50 years). The patients were

predominantly males (19 patients) and there were 6

female patients in the study population. The mechanism

of injury is listed in Table 1.

Table 1: Mechanism of Injury

1 Mango falling on face 42 Struck while cutting firewood 43 Soda bottle blast injury 14 Domestic Violence 35 Stone throw 86 Injury with Idiyappam makers spring

(Rice hopper) 27 Assault (MLC) 3

Majority of patients were referred within a week of

sustaining the blunt injury (20 eyes). 5 cases reported

within 2 weeks of sustaining injury. Associated anterior

segment findings included traumatic hyphema (3 eyes;

12 %); Sphincter tears (2 eyes; 8 %); angle recession

(5 eyes; 20 %); traumatic glaucoma (7 eyes; 28 %);

vitreous herniating into anterior chamber (3 eyes;

12 %); uveitis (2 eyes; 8 %); and traumatic mydriasis

in 4 eyes (16 %) (Table 2). Patients were taken up for

surgery after controlling the intraocular inflammation

and achieving medical control of IOP before surgical

intervention.Table: 2: Anterior Segment Findings

Findings No of eyes %

1 Hyphema 3 12%2 Sphincter Tear 2 8 %3 Angle recession 5 20 %4 Glaucoma 7 28 %5 Vitreous in AC 3 12 %6 Uveitis 2 8 %7 Tr Mydriasis 4 16 %

A dilated posterior segment evaluation was performed

and whenever Indirect Ophthalmoscopic view was poor,

a B.Scan USG was performed. Associated posterior

segment findings included vitreous haemorrhge (9 eyes;

36 %). Berlins oedema (2 eyes ; 8 %); Avulsed vitreous

base (1 eye ; 4 %), Retinal tear (3 eyes ; 12 %); Retinal

detachment (2 eyes; 8%), Choroidal rupture (1 eye ;

4 %) Fig. 1. (a-d). The preoperative best corrected visual

Fig. 1. (a-d) : Preoperative ocular findings. (a). Total

hyphema b) Dislocated lens (c) Bullous retinaldetachment (d) Choroidal rupture with organizedsubretinal blood

acuity ranged from Hand movements (HM) to 6/6 with

aphakic correction.

In all patients the surgery was performed under local

anaesthesia. Two patients with retinal detachment

underwent retinal detachment repair along with lens

removal and were left aphakic. In these 2 eyes

Perflurocarbon liquid (PFCL) was used to float the

dislocated lens into the pupillary area for where it was

removed through a limbal incision. The soft lens

dislocation was managed by performing a parsplana

December 2008 M. Chakrabarti et al. - Surgical Management of Dislocated lenses 373

lensectomy using an outcome cutter in 7 eyes. Phaco

fragmentation was performed in 9 eyes after floating

the lens on a small PFCL bubble. In the remaining 7

patients, the hard dislocated lens was floated up into

the pupillary space by injecting PFO after a thorough

vitrectomy.

In 22 patients a multiflex open loop ACIOL was

implanted into the anterior chamber under adequate

viscoelastic cover and the limbal section closed with 90

Nylon sutures. The residual PFO was aspirated and a

fundus examination with scleral depression was

performed before closure of sclerotomies.

Intraoperative complications encountered were an

iatrogenic retinotomy in one patient in whom an

intraoperative endolaser barrage retinopexy was

performed, residual retained PFCL and intraoperative

hyphema. Postoperative complications are listed in

Table 2.

Table 2: Post operative Complications

Macular Hole 1 4 %Epiretinal Membrane 4 16 %Macular Degeneration 4 16 %CME 1 4 %OD pallor 1 4 %Residual PFCL 1 4 %ILM folds 1 4 %

Retinal Detachment 1 4 %

15 patients achieved a final visual acuity of > 6/18. A

final visual acuity between 6/24 – 6/60 was possible

in 8 eyes and in 2 patients the final vision was less

than 6/60. Traumatic glaucoma was seen in 1 patient

who achieved adequate control with medical

management. The commonest cause for subnormal

vision was epimacular membrane and post traumatic

macular degeneration. Other caused included cystoid

macular oedema, optic disc pallor, choroidal rupture

and macular ILM folds. One eye developed a total RD

with advanced PVR, 5 years after the procedure. All

22 patients who underwent an ACIOL implant showed

clear corneas and no evidence of corneal endothelial

decompensation.

All patients were followed up and at each followup

visit their best corrected visual acuity, intraocular pressure,

degree of anterior segment inflammation, PAS formation

and macular integrity for presence of CME were assessed.

All eyes maintained good corneal clarity, no evident

anterior segment inflammation or PAS formation.One

patient each developed CME & Retinal detachment.

Discussion

If the crystalline lens dislocation is not associated with

other problems, it does not lead to any complications

on follow-up. The eye can be rehabilitated by contact

lenses or aphakic glasses. However, in some eyes the

dislocated crystalline lens has to be removed because

of some complications.

In general, the indications 5 for removal of a dislocated

crystalline lens includes impaired visual acuity, resulting

from obstruction of the visual axis by the dislocated

lens, development of complications such as phacolytic

uveitis, or glaucoma, retinal detachment, and vitreous

herniation into the anterior chamber resulting in a

cystoid macular oedema. A relative indication for

surgery is severe monocular diplopia.

Surgical techniques: Numerous surgical techniques 6,7,8

have been described for the management of dislocated

crystalline lenses, however, most have been abandoned

because of their limitations, complications and

complexities. The common technique currently used

to remove a crystalline lens dislocated into the vitreous

cavity includes performing a three port pars plana

vitrectomy 9. With this technique a thorough pars plana

vitrectomy with removal of as much of the basal vitreous

gel is performed using vitrectomy cutter The lens is

lifted into the midvitreous cavity and fragmented.

Frequently it may be necessary to crush the lens

between the endoilluminator and the fragmatome into

smaller fragments which can be easily emulsified and

aspirated. This procedure, though easy to perform can

be hazardous in view of the mechanical retinal damage

from falling lens fragments, or due to high energy of

the ultrasonic probe. There is also an added danger of

vitreous traction as the vitreous gets sucked into the

probe, if the vitrectomy has not been completed Retinal

damage is particularly likely to occur if these maneuvers

are performed when the retina is detached and mobile.

Therefore to remove the posteriorly dislocated crystalline

lens safely and effectively, the use of prefluorocarbon

liquids have been recommended 10,11,12. The advantage

of using perfluoro carbon liquid in removing crystalline

lenses dislocated into the vitreous cavity are as follows,


Disloc-dislocated, Tr-Traumatic, GRT-Gient Retinal Tear, Vit-Vitreous, AC-Anterior Chamber, VH-Vitreous

haemorrhage, Ret-Retinal, RT-Retinal tear, Chor: Choroidal, SB-Scleral buekh, PPV-parsplana vitrectomy,

PPL-Parsplana lensectomy, C3F

8-perflusopropane gas, LR-Lens removal, AC IOL- Anterior Chamber intraocular

lens, Frag- Fragmatome OD-Optic disc, ERM- Epiretinal membrane, Mac degn -Macular degeneration,

PFCL-Parsflurocarbon liquid, ILM-Internal limiting membrane

December 2008 M. Chakrabarti et al. - Surgical Management of Dislocated lenses 375

1. The perfluoro carbon liquid lifts the dislocated lens

from the retinal surface into the anterior vitreous.

2. In the presence of a retinal detachment, their high

specific gravity mechanically flattens out the retina.

3. The PFCL bubble forms a cushion which supports

the lens and prevents mechanical retinal damage

from falling lens fragments.

Therefore with the use of PFCL, the potential for

retinal damage is reduced. The surgical technique

includes performing a pars plana vitrectomy with

removal of as much basal vitreous gel, prior to lens

removal. After the completion of vitrectomy, PFCL is

injected into the vitreous cavity over the optic disc

floating up the dislocated lens into the anterior vitreous.

If the dislocated lens is associated with a retinal

detachment, the PFCL injection mechanically flattens

the retina against the retinal pigment epithelium,

displacing the subretinal fluid through a pre-existing

inferior retinal break into the vitreous cavity. The

dislocated lens is then fragmented in the anterior

vitreous cavity while floating on the PFCL. Small

fragments of lens matter that drop, float on the surface

of the perflurocarbon bubble and are easily aspirated.

Lens particles can get entangled in the basal vitreous

making its removal difficult. Damage to the peripheral

retina can occur in an attempt to remove these

entangled fragments.

If the dislocated crystalline lens is very hard it is

preferable to remove it through the anterior (limbal

route) using either a cryo or an irrigating vectis 13.

If the eye with the dislocated crystalline lens also has

an associated rhegmatogenous retinal detachment, the

scleral buckle is placed prior to the lens removal. After

removal of the lens, endolaser retinopexy is performed

around the tear and a PFCL air exchange is carried out

to achieve pneumohydraulic retinal reattachment.

Three elements are key to a successful lens

fragmentation techniques 13 are

1. Adequate vitrectomy avoids unintended vitreous

traction during phaco fragmentation.

2. Reducing fragmentation power to only 5 % to 10 %

facilitates nuclear extraction by continuous

occlusion of the suction ports and avoids projectile

fragments. This maneuver also minimizes the risk

of fragments dropping on to retinal surface.

3. Fragments should be aspirated and brought to

midvitreous cavity before ultra sonic fragmentation,

if PFCL is not used.

There are several reports comparing various IOL

fixation techniques in aphakic eyes 14,15,16,17,18. Results

of these studies have conclusively shown that there is

no statistically significant difference between the

various IOL types with respect to postoperative

vision,central corneal thickness and intraocular

pressure. Implanting a multiflex open loop design AC

IOL into the anterior chamber is a viable option provided

there is no corneal endothelial decompensation,

compromised angles or loss of iris tissue.

In this study, all patients with ACIOL implants were

followed us for atleast a minimum period of 24 months.

Corneal clarity, endothelial cell counts, central corneal

thickness, presence or absence of anterior chamber

inflammation, peripheral anterior synchiea formation,

intra ocular pressure, and presence of cystoid macular

oedema were assessed as each follow up visit and found

stable expect for CME in one patient.

Thus successful management of severe blunt injury

involves a thorough preoperative work up, proper

surgical planning and meticulously tailored

postoperative management and follow up.

References

1. William A Townsend; Pico MP; Hilel Lewis MD.

Vitreoretinal Surgery for Ocular Trauma Chapter 117.

2. Higget PE; Pince KJ; Barlow. W et al. Ocular Trauma in

an Urban Population; Study of 1132 cases. Ophthalmol

1992; 97: 581-596.

3. Maguire AM; Enger. C; Elliot et al. Computerized

Tomography in the Evaluation of Penetrating Ocular

Injuries. Retina 1991; (II): 405 -410.

4. Nicholas MH; Brophy D. P et al. Ocular Trauma –

Evaluation with Ultra Sound. Radiology 1995; 195:

423 -427.

5. Lewis H Blumenkraz; Chang. S .Treatment of Dislocated

Crystalline Lenses and Retinal Detachment with

Perfluoro carbons. Retina 1992; 12:299-

6. Demeler. U; Sautter. H . Surgery in Subluxated Lenses

in Adults. Dev Ophthalmol 1985 ; 11 : 162-

7. Illif CE; Kramar. T. A working guide for the management

of Dislocated Lens. Ophthalmic Surg. 1971 ; 2: 251-

8. Urrets; Zavalia. A Displacement of the Crystalline Lens.

Dev. Ophthalmol Vol 59, 1989.


9. Hutton W L; Snyder WD; Vaiser A. Management ofSurgically Dislocated Intra Retinal Lens Fragments byPars Plana Vitrectomy.

10. Liu.K; Peyman G.A; Chen. M; Chang.K . Use of HighDensity Vitreous Substitute in Removing PosteriorlyDislocated Crystalline Lens or Intraocular Lenses.Ophthalmic Surg 22: 503; 1991

11. Shapiro M.J; Resnick K. I; Kim. S. H; Weinberg. A.Management of Dislocated Crystalline Lens with aPerfluoro Carbon Liquid. Am. J. Ophthalmol 112; 401;1991

12. Hilel Lewis. MD; German Sanchez MD. The use of PFCLin the repositioning of posteriorly dislocated IOLs.Ophthalmol 1993; 100; 1055-1059.

13. W. Smiddy; H. J. Flynn. Managing lens fragments anddislocated PCL’s after Cataract Surgery. Focal Points:1996

14. Implantation of Kelman Style Open loop AC IOLs duringKeratoplasty for aphakic and pseudophakic bullouskeratopathy – A comparision with Iris Sutured PC IOLs.Ophthalmol 1991; 98:875-880.

15. Richard .M.Davis MD, Douglas Best, Gregory E Gilbert.Comparison of IOL fixation techniques performedduring penetrating Keratoplasty. Am.J.Ophthalmol.111,June 1991:743-749.

16. Oliver.D.Schein MD, MPH, Kenneth.R.Kenyon MD,Roger .F. Steenert MD, et al A randomised trail of IOLfixation techniques with penetrating Keratoplasty.Ophthalmol 1993, 100, 1437-1443

17. Leaming DV. Practice styles and preferences of ASCRSmembers – 1994 survey. J Cataract Refract Surg 1995;21:378-385

18. Lawrence E Weene MD. Flexible Open Loop AC IOLImplants .Ophthalmol 1993, 100; 1636-1639


Intravitreal BevacizumabDr. Sonia Rani John DNB, Dr. Meena Chakrabarti MS, Dr. Valsa Stephen MS, Dr. Arup Chakrabarti MS

Angiogenesis is a highly complex, dynamic process

regulated by a number of pro and anti antiogenic

molecules. The vascular endothelial growth factor

(VEGF) and its receptors play a vital role in normal

and pathologic angiogenesis. Activation of the VEGF

receptor pathway triggers a network of signaling

processes that promote endothelial cell growth,

migration and survival from pre existing vasculature,

differentiation, and mobilization of endothelial

progenitor cells from the bone narrow into the

peripheral circulation. In addition, VEGF increases

vascular permeability leading to deposition of proteins

in the interstitium that facilitate the process of

angiogenesis.

There are many ocular diseases in which angiogenesis

plays a major role; for example, proliferative diabetic

retinopathy, age - related macular degeneration

(ARMD), retinal vascular occlusion, sickle cell

retinopathy and retinopathy of prematurity. VEGF has

been identified in neovascular membranes in both

diabetic retinopathy and ARMD and intraocular levels

of the factor correlate with the severity of

neovascularization in diabetic retinopathy. Therapeutic

antagonism of VEGF in animal models result in

significant inhibition of both retinal and choroidal

neovascualrisation as well as a reduction in vascular

permeability 1, 2.

Bevacizumab (Avastin; Genentech Inc, South San

Francisco, CA) is a full length humanized murine

monoclonal antibody against the VEGF molecule. The

amino acid sequence of this monoclonal antibody is

93 % of human origin and 7 % murine 3. Bevacizumab

is approved by the Food and Drug Administration for

treatment of metastatic colorectal cancer in 2004 and

is in phase III trial for advanced breast cancer and

advanced renal cancer. VEGF selectively stimulates

endothelial cells by binding to two receptors, VEGFR -

1 and VEGFR-2, which respond in a typical fashion to

ligand binding by activation of signal transduction

cascades. Bevacizumab can theoretically inhibit the

activity of both receptors.

The labelled indication of Avastin is for the treatment

of colon cancer. Its use in the eye is therefore off-label;

no robust scientific data exist on its safety and efficacy,

all the positive reports have short follow- ups. Off-label

use of drugs is not illegal. Physicians and surgeons are

allowed to do this. The fact that it is a common practice

does not make it safe. There may be a risk of unexpected

adverse outcomes, but this is also true of labelled use

of new drugs.

Bevacizumab is a clear to slightly opalescent, colorless

to pale brown solution with a pH of 6.2. It is supplied in

100 mg and 400 mg preservative free single use vials

to deliver 4 ml or 16 ml of Bevacizumab (25 mg/ ml).

It is formulated in trehalose dihydrate, sodium

phosphate (monobasic, monohydrate), sodium

phosphate polysorbate and water for injection. The

most commonly used dose for intravitreal injection

currently is 1.25 mg (0.05 ml) although upto 2.50 mg

(0.1 ml) may be used 4. The stability and anti VEGF

activity of bevacizumab that was drawn up from the

vial and refrigerated or frozen for later use is currently

not known. The question as to how long the withdrawn

samples can be stored in a syringe, without affecting

the stability of the product, is relevant to our clinicalChakrabarti Eye Care Centre, Kochulloor, Trivandrum - 695 011,


O C U L A R

PHARMACOLOGY


practices. In addition, as clinical trials are designed, it

is important to maintain consistency between samples

of bevacizumab, to assess its efficacy and establish the

optimum dose for each disease. Studies have shown

that there is minimal change in concentration of

bevacizumab in the samples at 3 months and minimal

further change from 3 months to 6 months. Given the

potential error in accurately dosing 0.05 mL of drug in

a clinical setting, a 10 % change in drug concentration

at 3 months is insignificant. It is interesting to note

that at 3 months and 6 months, bevacizumab in both

the vial and stored syringes degrades minimally. The

manufacturer’s guidelines state that bevacizumab vials

must be refrigerated at 20 C to 80 C ( 360 F to 460 F),

should be protected from light, and should be stored

in the original carton until time of use. The

manufacturer recommends that bevacizumab be used

within 8 hours of being opened when diluted for

intravenous administration and that it should be neither

frozen nor shaken.

While ranibizumab (Lucentis) is derived from

bevacizumab, the 2 molecules have quite different

pharmacokinetics and VEGF–binding affinity.

Ranibizumab (48 K Da) 2 is an antibody fragment

approximately one–third the size of bevacizumab (148

K Da) 3 that penetrated the retina much better than a

full sized antibody after intravitreal injection in

monkeys. In June 2006, the FDA approved Lucentis

for the treatment of patients with neovascular AMD.

Ranibizumab has also been modified to increase 100

times its affinity for the VEGF-A receptor binding

domain. The vitreous and serum half lives of

bevacizumab are much longer than those of

ranibizumab (5.6 Vs 3.2 days ; < 21 days Vs 15 hours

respectively) raising the possibility of both local and

systemic over dosage if bevacizumab is used in the same

way as ranibizumab. Because subretinal

neovascularisation causes breakdown of blood retinal

barrier, it is inevitable that drugs injected into the eye

will appear to inhibit important physiological functions

of VEGF such as wound healing and the formation of

collateral circulations in myocardium and peripheral

vascular ischemia.

The last two years heralded the use of intravitreal anti-

VEGF injections especially the use of intravitreal

Bevacizumab (Avastin) injection in the management

of ocular neovascularization arising from diverse

etiologies. Age Related Macular Degeneration

(ARMD) is a common cause of blindness that has a

pathogenic link to neovascularization. The tell tale signs

of AMD include the presence of drusen, thickening of

Bruch’s membrane and hypo and hyper pigmented

areas of RPE cells. The development of choroidal

neovascular membrane in the form of wet AMD leads

to the growth of incomplete vessels. Leakage from these

vessels cause accumulation of subretinal exudates and

hemorrhages and brings about cell death and reactive

gliosis with severe vision loss. Excellent results of

regression of choroidal neovascular membranes

associated with age related macular degeneration 5, 6

following intravitreal Bevacizumab has been reported

by various authors. Age related macular degeneration

is the leading cause of irreversible vision loss among

the elderly and macular neovascularisation is the most

common cause of severe vision loss 7. Photodynamic

therapy is one current treatment for neovascular AMD

patients with subfoveal neovascularisation. Although

photodynamic therapy (PDT) is superior to placebos

for preventing moderate vision loss in patients with

relatively small minimally classic and occult lesions,

there is little chance of visual improvement in these

patients. Of all the angiogenic factors, VEGF is

implicated as the major stimulus responsible for

neovascularisation in AMD. Once injected into the eye,

the proposed mechanism of action of anti VEGF agents

involve penetration of the drug through the retina

followed by competitive inhibition of VEGF in the extra

cellular space 8.

In a recent off -label study, patients with neovascular

ARMD were treated systematically with bevacizumab

(5 mg/kg) 9. An open label prospective clinical study,

the systemic Avastin for Neovascular AMD (SANA)

study, proposed that systemic (B) could leak from CNV

and blind extra cellular VEGF and that inhibition of

extracellular VEGF could improve visual outcomes.

Systemic (intravenous) bevacizumab was associated

with a significant increase is visual acuity and decrease

in central retinal thickness by OCT 1 week after therapy.

These preliminary results are promising 9. In addition

to the ocular side effects, there were some systemic

disadvantages associated with systemic administration

of bevacizumab; the most significant disadvantage was

December 2008 S.R. John et al. - Intravitreal Bevacizumab 379

the possibility of life threatening adverse events. There

was an increased risk of potentially fatal

thromboembolic events in patients with advanced

metastatic colorectal cancer receiving concomitant

chemotherapy and bevacizumab when compared to

patients receiving chemotherapy alone. Other potential

systemic side effects included hypertension, epistaxis,

hemoptysis, proteinuria, wound healing complications

and gastrointestinal haemorrhage.

Another study has enrolled more than 250 patients to

date for intravitreal Avastin therapy and data for the

first 53 patients with 3 - month follow-up is now

available. The first set of data released in this ongoing

study shows similar efficacy to that of Lucentis with

notably 44 % of patients gaining greater than or equal

to three lines of visual acuity.

The major reservation for the off-label use of Avastin

in treatment of CNV continues to be debate over the

possible systemic side effects. During the initial

investigational studies of Avastin for the treatment of

colon cancer, patients were found to have significant

side effects including increases in blood pressure and

doubling of the risk for thromboembolic events

including myocardial infarctions and cerebral vascular

accidents. Proponents of Avastin contend that those

complication rates were based on systemic administration

of much larger dosages every 2 weeks for upto a year

or longer. The use of Avastin intravitreally with a

substantially lower dose would result in lower systemic

peak levels and monthly dosing would have lower total

dosage, both of which can reasonably be expected to

induce fewer systemic side effects. Moreover, the

reported risk of thromboembolism with Avastin therapy

is based on a cancer population receiving concomitant

chemotherapy, clearly at great risk for such events. An

increase in thromboembolic events has not been

observed in the intravitreal study thus far; however,

further studies are needed to provide more conclusive

data on the safety and efficacy of Avastin. In February

2008, the National Eye Institute (NEI) announced the

start of a multicenter clinical trial to compare the

relative safety and effectiveness of Lucentis and Avastin

to treat advanced AMD.

Recent studies 10 show that intravitreal bevacizumab

leads to rapid regression of iris and angle

neovascularization and should be investigated

thoroughly as an adjunct in the management of

neovascular glaucoma. These studies have

demonstrated the safety and efficacy of intravitreal

Bevacizumab in causing regression of ocular

neovascularization. Kahook MY et al 10 and Davidorf

F H 12 et al have, in 2006, proved the efficacy of intravitreal

Avastin injection as an adjunct in the management of

neovascular glaucoma. In these studies rapid regression

of iris neovascularization and clearing of corneal

oedema occurred within 48 hours giving symptomatic

relief to the patient along with short term IOP control.

Thus IVB as an adjuvant in the management of

neovascular glaucoma may offer a more scientific

rationale for the treatment of the causative neovascular

trigger, might prevent further PAS formation and extension

of secondary angle closure. It also facilitates early

initiation of PRP, further dampening the neovascular

trigger. Prospective randomized trials are required to

validate the efficacy of IVB alone as monotherapy and

its use in conjunction with maximal anti glaucoma

medications, ARC, CPC and cyclo cryotherapy. Long

term results, chances of recurrence and the options to

manage them can only be answered by a prospective

trial in a larger series with longer follow up data.

Recalcitrant diabetic macular edema is

characterized by the accumulation of plaques of hard

exudates in a grossly oedematous retina not amenable

to the standard modalities such as photocoagulation,

intravitreal injection of triamcinolone acetonide or

vitrectomy and showing a very poor visual potential.

These patients usually have a poorly controlled glycemic

status of long duration with associated co-morbid

conditions such as systemic hypertension, dyslipidemia

and chronic renal failure 13. Studies 6 reveal reduction

in central retinal thickness by OCT scan and

improvement in visual acuity in these patients after

intravitreal injection of bevacizumab.

Intravitreal bevacizumab results in significant decrease

in macular edema due to central retinal vein

occlusion 14, 15. Retinal vein occlusion is associated

with increased intravitreal levels of VEGF, particularly

in cases complicated by neovascularisation. Eyes with

CRVO show evidence of intraretinal VEGF mRNA

expression. Inhibition of VEGF by anti sense oligo deoxy

nucleotide or anti VEGF monoclonal antibody resulted

in reduction or complete prevention of iris


neovascularisation in animal models of CRVO 16. Since

intraocular injection of VEGF causes retinal

microvascular abnormalities and retinal ischemia, and

since retinal vein occlusion itself causes increased intra

ocular VEGF that varies with disease severity, inhibition

of VEGF in human CRVO has therapeutic potential.

The lack of controlled studies leaves open questions

regarding the safety of intravitreal injection of

Bevacizumab. The literature to date suggests that IVB

is relatively safe in the short term with few severe ocular

and systemic side effects. The systemic risk from

intravitreal injections of drugs in adults are relatively

low because the amount of drug that is absorbed into

the systemic circulation is then diluted substantially

by blood volume. Nevertheless, beneficial cross over

effects have been reported (eg; as a reduction in

neovascularization of the disc in the fellow eye of an

eye that received anti VEGF agent). Published ocular

side effects include uveitis, subconjunctival

haemorrhage, transient blurred vision, vitritis, lid

irritation, ocular discomfort, foreign body sensation,

corneal abrasion, elevated IOP, cataract, posterior

vitreous detachment, endophthalmitis, subretinal

haemorrhage, RPE tears, and retinal detachment 17. Anti

VEGF agents act by reducing angiogenesis and arresting

the CVNM 18. The same pathology of fibrovascular tissue

contraction may be at work in RPE rips following anti-

VEGF therapy. The risk of an RPE rip should be

considered with treatment for anti VEGF agents in cases

with fibrovascular PED. The lack of controlled studies

leaves questions as to the frequency of the various

reported side effects.

Kernt et al 19 measured IOP in 45 patients undergoing

IVB and reported 2 cases of elevated IOP (22 and 28

mm of Hg) immediately following injection, both of

which resolved without therapy. Although the frequency

of elevated IOP after IVB appears to be low, the long

term consequences of transient IOP elevation could be

significant not only for those with already compromised

optic nerves, such as in patients with glaucoma, but

also in terms of risk of vascular occlusive events, such

as retinal venous or arterial occlusion. The mechanism

for acute elevation in IOP has been postulated to be

mechanical, secondary to increased vitreous volume.

If this is the case, in high risk cases one might consider

anterior chamber tap prior to injection. Certain

precautions have to be taken to limit the risks and

complications associated with intravitreal injection of

anti- VEGF agents. So to reduce the risk of

endophthalmitis associated with intravenous injections,

5 % povidone iodine can be applied to the conjunctival

cul de sac. To avoid cataract or possible injury should

the patient move, forceps is used to stabilize the globe

in the region anesthetised before administering the

injection and ensure that the angle of the needle path

into the vitreous cavity avoids the lens. After the

injection, the intraocular pressure is measured and the

patency of central retinal artery (CRA) is checked by

indirect ophthalmoscopy. If there is loss of vision, or

the patency of the CRA is compromised, a paracentesis

has to be performed.

It should be explained to the patients that the drug is

approved for use in the human body, but has either not

been approved by intravitreal route or not for use in

this particular disease. A large scale study has not been

conducted, and therefore the data to support this use

of the agent are limited and also there are small case

series that suggest the agent may be benefit.

Intravitreal bevacizumab did not appear toxic to the

retina in albino rabbits at a concentration of 2.5 mg

based on electrophysiologic studies 20, 21. Maturi R K et

al 12 in his study concluded that intravitreal use of

Bevacizumab resulted in improvement of mf – ERG

macular function responses and relatively stable G -

ERG responses. The macular electrophysiologic

response suggested that macular function improved

with treatment. G -ERG suggested that there is no

significant measurable photoreceptor toxicity with the

use of IVB over short term 22.

The use of intravitreal bevacizumab for the treatment

of chorioretinal diseases mediated by VEGF has spread

throughout the globe in less than six months from the

time of the first case reports. The most obvious reasons

for the rapid adoption of intravitreal Avastin include

the rational scientific basis of treatment, the

overwhelming efficacy reported for the closely related

drug known as Lucentis (Ranibizumab, Genentech Inc),

the presence of an enormous unmet need to prevent

blindness from VEGF–mediated diseases, the visual

acuity and anatomic improvements appreciated by

patients and treating physicians, the apparent short

term safety and the affordable low cost of the drug.

December 2008 S.R. John et al. - Intravitreal Bevacizumab 381

Neovascularization is a key pathophysiologic mechanism

of a wide variety of diseases, making the factors that

mediate angiogenesis an attractive therapeutic target.

Although the brunt of clinical research in the inhibition

of ocular neovascularization has been on CNV related to

AMD, researchers are exploring the potential for benefit

from the utilization of these drugs in other diseases

such as diabetic retinopathy, vascular occlusion, and

macular edema. While the gamunt of retinal and

choroidal neovascular diseases varies greatly, the

common source of pathogenesis, incompetent vessels and

the compromise of the blood retinal barrier, has

provided for significant advancement in the treatment

of these diseases. Despite all the advancements in

treatment discussed here, the collection of ocular

diseases caused by neovascularization continues to

create significant morbidity among patients.

References

1. Aeillo LP, Pierce EA, Foley ED, et al. Suppression ofretinal neovascularisation in vivo by inhibition ofvascular endothelial growth factor (VEGF) using solubleVEGF receptor chimeric proteins. Proc Natl Acad SciUSA 1995;92:10457-10461.

2. Quam T, Xu Q, Joussen AM, et al. VEGF initiated blood-retinal barrier breakdown in early diabetes. InvestOphthalmol Vis Sci 2001; 42:2408-2413.

3. Sophie J.Bakri, MD, Melissa R, Snyder. PhD, et al. Sixmonth stability of Bevacizumab (Avastin) binding tovascular endothelial growth factor after withdrawal intoa syringe and refrigerator or freezing.Retina 26:519-522, 2006.

4. Rosenfeld PJ, Schwartz SD, Blumenkranz MS, et al.Maximum tolerated dose of a humanized anti-vascular

endothelial growth factor antibody fragment for treatingneovascular age-related macular degeneration.

Ophthalmology 2005; 112:1048–1053.

5. Rosenfeld P J, Moshefeghi A et al. OCT findings after

intravitreal Bevacizumab (Avastin) for neovascular agerelated macular degeneration. Ophthalmic Surg LasersImaging 2005; 36:331-5.

6. Haritoglou C, Kook D, Neubauer A, Wolf A, Priglinger

S, Strauss R, Gandorfer A Avery R L, Pieramici D J,Rabena MD et al. Intravitreal Bevacizumab (Avastin)for neovascular age related macular degeneration.

Ophthalmol 2006; 113: 363-372.

7. Rosenfeld PJ, Moshfeghi AA, Puliafito CA. Opticalcoherence tomography findings after an intravitrealinjection of bevacizumab (Avastin®) for neovascular

age-related macular degeneration. Ophthalmic SurgLasers Imaging 2005; 36:331–335.

8. Avery RL, Pieramici D, Rabena M, Castellarin A,Nasir M, Giust M. Intravitreal bevacizumab (Avastin)for neovascular age-related macular degeneration.Ophthalmology 2006.

9. Michels S Rosenfield PJ, Puliafite CA. Systemic

Bevacizumab therapy (Avastin) for neovascular ARMD,

12 week results of an uncontrolled open- label study.

Ophthalmology 2005; 112: 1035-1047.

10. Milko E, Hiev, Diego, Domig MD, Intravitreal

Bevacizumab (Avastin) in the treatment of Neovascular

Glaucoma. Am J. Ophthalmol 2006; 142:1054-1056.

11. Haritoglou C, Kook D, Neubauer A, Wolf A, Priglinger S,

Strauss R, Gandorfer A, Ulbig M, Kampik A. IVB

(Avastin) therapy for persistent diffuse diabetic macular

edema. PMID: 17151486 [PubMed - indexed for

MEDLINE]

12. Maturi R K, Bleau LA, Wilson DL, Retina 2006 Mar;

26 (3): 270-274.

13. Reichel E. Intravitreal bevacizumab for choroidal

neovascularization and cystoid macular edema: a cost-

effective treatment? Ophthalmic Surg Lasers Imaging

2005; 36:270–271.

14. Ip MS, Gottlieb JL, Kahana A, et al. Intravitreal

triamcinolone for the treatment of macular edema

associated with central retinal vein occlusion. Arch

Ophthalmol 2004; 122: 1131–1136.

15. Pe’er J, Folberg R, Itin A, et al. Vascular endothelialgrowth factor upregulation in human central retinalvein occlusion. Ophthalmology 1998; 105:412–416.

16. Tolentino MJ, Miller JW, Gragoudas ES, et al.Intravitreous injections of vascular endothelial growthfactor produce retinal ischemia and microangiopathyin an adult primate. Ophthalmology 1996; 103:1820–1828.

17. Lynch SS, Cheng CM. Bevacizumab for neovascularocular diseases. Ann Pharmacother 2007; 41:614-25.

18. Adamis AP, Shima DT. The role of vascular endothelial

growth factor in ocular health and disease. Retina 2005;

25: 111-118.

19. Kernt M, Nuebauer A S, Kampila a. Intravitreal

Bevacizumab (Avastin) treatment is safe in terms of

intraocular and blood pressure. Acta Ophthalmol Scand

2007; 85: 119-20.

20. Loewenstein A, Zemel E, Lazar M, Perlman I. Drug-

induced retinal toxicity in albino rabbits: the effects of

imipenem and aztreonam. Invest Ophthalmol Vis Sci

1993; 34:3466–3476.

21. Han DP. Intravitreal human immune globulin in a rabbit

model of Staphylococcus aureus toxin-mediated

endophthalmitis: a potential adjunct in the treatment

of endophthalmitis. Trans Am Ophthalmol Soc 2004;

102:305–320.

22. Hood DC, Birch DG. A computational model of the

amplitude and implicit time of the b-wave of the human

ERG. Vis Neurosci 1992; 8:107–126.


High-End Phaco Systems: A ComparisonDr. Ashley Thomas Jacob MS DNB MRCOphth

High End Phaco: Excellence at your finger

tips

There are several high end phaco designs available in

the market today. I have ventured to analyze only those

that offer some value and uniqueness that would help

the individual surgeon in bettering his technique and

enable superior marketing of his surgical unit.

In this issue, the spot light is on three designs that have

superior degree of innovation and have dominated

scientific meetings in US, Europe and in India.

Oertli Os3

Country of Origin: Switzerland

Website: www.oertli-instruments.com

Sold & Serviced by: Toshbro Medical Equipments

Oertli has been a leader in innovative concepts that

are rarely well marketed in India. The quality of its

product range has been never justified by the various

distributors handling its products. This has been the

failure of an otherwise exceptional product.

Oertli has several innovations to its name like the 6-

crystal Handpiece, Co-MICS (coaxial micro phaco), dual

linear foot pedal, etc.

User Interface: Large LED display and push button

control &Audio. The display unit is a dated design that

cries out for change.

I/A System: The OS3 fluidics system comes with the

TwinVac cassette (250ml) and integrated pressure

sensor. The cassettes are available as single use or

autoclavable and these can be emptied.

Venturi and peristaltic double pump switchable (from

pedal, remote control or panel) during surgery with

the dual function cassette that supports both pumps.

Air free fluidics system: The absence of air in the

aspiration path has multiple advantages like immediate

response to pressure changes, instant build up of suction

power and stable anterior chamber.

Oertli claims to employ an AC Guard system that eliminates

vacuum surges completely even at highest levels of

vacuum. The company says that there is no possibility

of contaminations from pressure sensor as pressure is

sensed without contacting the aspiration liquid.

Reflux function is selectable, from bottle or with pump

reverse (150ml).

Ultrasound Phaco: Six-Crystal Design Phaco hand

piece.

CMP - cool phaco mode for bimanual cool micro incision

phaco.

Bipolar Klöti RF-capsulotomy: This form of

capsulotomy is unique to Oertli designs.

Anterior Segment Vitrectomy: Single use

guillotine cutter with selectable cutting rate of upto

1200cuts/minute. Extendable to Vitreoretinal Surgery

Dual Linear Pedal: The programmable dual linear

pedal is equipped with its own controller. Not only can

you assign preferred functions to the various pedal

elements, you can also individually set the position

points and the resistance at the position points.

*Skill Enhancement needed: NONEMulamoottil Eye Hospital, Kozhencherry

O P H T H A L M I C

INSTRUMENTATION

December 2008 A. Thomas - High end phaco systems 383

Alcon Infiniti

Country of Origin: USA

Website: www.alconlabs.com

Sold & Serviced by: Alcon India

Alcon has consistently provided surgeons with

innovative technologies in the field of cataract micro

surgery. Although expensive to purchase and maintain,

the quality is unmistakable. The groundbreaking Legacy

is a case in point. Now, with the Infiniti, we have a

worthy successor.

The Infiniti has several innovations like the Ozil

Torsional Phaco, AquaLase system, and Alcon’s own

version of the micro phaco (Intrepid).

User Interface: Touch screen & Audio

I/A System: Alcon calls it the Fluidic Management

System.

Alcon claims that the FMS has a low-compliance (rigid)

design with molded fluid paths and thick-wall polymer

aspiration tubing that decrease post-occlusion surge and

increase fluidic response and accuracy.

The pump mechanism has tapered rollers designed for

instantaneous, smooth peristaltic response and has

greater pumping capability, with forward and reverse

actuation up to 100cc per minute.

Ultrasound Phaco: OZil Torsional Handpiece:

The hand piece delivers side-to-side oscillating

ultrasonic movement. With virtually no repulsion, it

delivers a level of followability that is unmatched.

Torsional phaco utilizes ultrasonic oscillatory movement

that can benefit lens removal for all lens densities. The

unique movement of torsional phaco shears the lens

material, providing decreased repulsion (no jack hammer

effect) while improving the thermal safety profile over

traditional ultrasound. There are multiple surgical

benefits to decreased repulsion: increased followability,

reduced turbulence, and increased cutting efficiency.

Side-to-side movement delivers increased cutting

efficiency by emulsifying lens material with both

directions of movement which has the potential to

reduce fluid usage and increase your surgical efficiency.

Less frictional movements within the incision and lower

frequency (32kHz) reduce the risk for thermal injury

thus allowing the use of sealed incisions and continuous

torsional modes increasing surgical efficiency.

The design facilitates the emerging trend of micro-

coaxial phaco.

The titanium hand piece with 4 crystals weighs only

60 grams.

AquaLase Liquefaction Device: The innovative

AquaLase Liquefaction Device offers an alternative to

ultrasound in soft to medium density cataract lenses

while claiming reduced surgical complications.

Warmed pulses of BSS sterile irrigating solution are

delivered through a smooth polymer tip to delaminate

and separate lens tissue. Each pulse is only 4 mL and is

delivered in a “scoop-like” energy pattern. The smooth

capsule-friendly tip is designed to improve your ocular

safety with a “more in the bag” technique. The fluidic

pulses are individually made and delivered with no

mechanical motion of the tip and the pulse energy

density is quickly dampened within the fluid of the

anterior chamber, reducing risk to surrounding tissue.

AquaLase allows change of pulse strength by altering

volume and velocity; vary pulse rate, and activate burst,

with variable rest intervals and decreased repulsion of

nuclear material.

INTREPID Micro-Coaxial System: Micro-coaxial

System delivers a complete micro-incision solution,

allowing the surgeon to perform surgery safely and

efficiently through a single incision without altering

the normal technique.

*Skill Enhancement needed: Since the Ozil works

only with the Kelman tip, the surgeon would have to

devote time to re-train himself if used to working with

straight tips.

AMO Whitestar Signature

Country of Origin: USA

Website: www.amo-inc.com

Sold & Serviced by: AMO India

User Interface: Touch screen & Audio

I/A System: AMO calls it the Fusion Fluidics. It claims

to provide increased chamber stability and safety by

anticipating intraocular changes and proactively


adjusts, so chamber stability is never compromised -

even at higher vacuum and flow settings, with any

technique, on any lens type.

The Fusion Fluidics surge-prevention technology allows

the use of high vacuum and flow settings to reduce

phaco time and increase efficiency while improving

chamber stability by anticipating occlusions and

preemptively adjusting vacuum before occlusion breaks.

The system has the ability to switch between a true

peristaltic pump and true venturi pump on-the-fly.

During a procedure, the surgeon can switch instantly

into venturi mode for additional vacuum and holding

power. This capability can be extremely useful in

teaching institutions, allowing the flexibility to use both

modalities in one system.

WHITESTAR ICE Technology

Cavitation is a recognized source of ultrasonic cutting

power. When bubbles strike, high energy manifesting

as a localized implosion destroys nuclear material.

WHITESTAR ICE Technology is designed to maximize

the cavitational potential of phaco energy to optimize

surgical technique

Theoretically, an initial punch at the beginning of each

ICE Pulse allows gas-rich BSS to flow between the phaco

tip and cataract material, acting as a transient cavitation

accelerator

The ICE Pulse amplitude punch can be from 0% to 12%

of total pulse power and can be set to increase, decrease

or stay constant in each phaco setting.

Ultrasound Phaco: Ellips Transversal

Ultrasound

The Signature System now comes with Ellips

Transversal Ultrasound as an answer to Alcon’s Ozil.

To work around Alcon’s patent, the longitudinal and

transversal ultrasound has been simultaneously

blended. This, AMO claims, has been designed for

efficient cutting that doesn’t require a change in

technique and works with any tip style—straight or

curved. And it’s true! There is no skill enhancement

required unlike with Ozil.

The system is optimized with Micropulse Technology

for followability and to minimize the risk of thermal

damage.

*Skill Enhancement needed: NONE

Conclusion

Buying a High End phaco system involves a lot of

money. So it is wise that such a decision is reached

after careful deliberations on the feasibility of such an

investment. The bare truth is that the purchase is most

often made to satisfy one’s own ego (which is important,

but cannot be the sole point on which to base the

purchase).

The purchase would be deemed financially viable if

the surgeon would be performing a minimum of 30

cases a month. As with any surgical unit, break even

has to be achieved by 12-18 months.

Alcon Infiniti would be a good buy if considered purely

on the merit of the investment. The unit has a fairly

good number of installations and has proved to be

largely trouble free. AMO Signature with Ellips would

come a close second losing out on the number of

installations. Oertli would raise concerns on the

distributor’s ability to sustain the unit and their

distributorship which could change hands.

Whatever your choice, it has be complimented by good,

ethical in-house marketing activities.

(To be continued)

December 2008 A. Thomas - High end phaco systems 385

Spectacles- What We Do Not KnowDr. Bindu N. Das MS DO MBA(HM)

Introduction

Spectacles is a common, cheap and easy method of

prescribing corrective lenses in patients with refractive

errors and presbyopia.

Working knowledge about spectacle lenses , frames and

process of dispensing will help an ophthalmologist to

give exact instructions to the optician. This will go a

long way in ensuring patient satisfaction with glasses.

What is a Spectacle?

Spectacle is defined under British standard as an optical

appliance comprising lenses and a frame with sides

extending towards ears (Fig 1).

I .Spectacle Frames

A. Parts of a Spectacle frame

Each frame has two main parts - Front & Side.

� Front consist of rims, bridge,joints and lugs.

� Rims

May be complete or incomplete or full rim, rimless(3ps)

and half rim(supra)

Lenses are supported by nylon or steel wires.

� Bridge

Is that part of front which forms the connection between

two rims (Fig. 2). Bridges may be of three basic types

1. Regular:-it rest on the nose with full surface in

contact.

2. Insets bridge/Keyhole:-Projects behind the frame

plane so that area of contacts has behind the lenses

plane.

3. Saddle Bridge:-Combination of regular and insets

bridges. It mainly distributes the weight of

spectacles on top as well as side of nose.

4. Modified saddle bridge

5. Adjustable nose pads:-Allow for good fit.

Different types of bridges

� Lugs: Projection on sides to which side pieces are

attached.

� Side Pieces / Temples are the principal parts

that fix spectacles to ear. They are made up of

metals and plastic in combination.

B. SPECTACLE FRAME MATERIALS

An ideal spectacle material must be durable , adjustable,

non allergic, non inflammable, non corrosive and

preferably of low cost.

� Plastic frames � Shell frames

� Nylon frames � Metallic

� CombinationRegional Institute of Ophthalmology, Calicut

Fig. 1. Parts of a Spectacle

O P H T H A L M I C

INSTRUMENTATION


a) Plastic Frames:-Thermoplastic material is are used

usually as these can be heated and cooled without losing

their plasticity. Cellulose acetate, Cellulose nitrate,

Cellulate propionate, Perspex(Synthetic acrylic resin-

PMMA),Epoxy resins are examples

b)Shell frames:-Made from shell of Hawks bill turtle

found in West Indies and Seychelles. They are durable,

have attractive colours and mottling and are easy to

maintain.

c) Nylon:-were used in making spectacles for children

where chances of breaking were high.

d)Metallic frames:-These are stable, quite adjustable,

non inflammable and non allergic (except nickel) and

pleasing. They are inexpensive and can be mass produced.

Variety of materials like stainless steel, nickel, silver

(German Silver), anodized aluminum, gold, titanium

and memory metal are used for making frames.

e)Combination frames

C. FRAME STYLES

Spectacle frames are available in different styles. They

include Full Frame, Combination Frame, semi rimless

and Rimless (Drill mount).

D.FRAME SELECTION

Correct fit and selection of frames is an essential part

of accurate dispensing. Frames must be rigid, strong,

and light and must be comfortable for the wearer.

Points to be taken into account:- (Fig. 3)

- Temporal hairline margin distance

- IPD

- Shape of the face

- Physical features of face.

- Nose bridges and suitable side arms.

- FTB

- Pantoscopic tilt

- Fitting triangle

Computer software programs are available by which

we can match the facial form with different type of

spectacle styles and select the suitable frames.

FTB: Distance between back surfaces of the front to

the ear. Too large FTB will cause the frame to sag.

Pantoscopic Tilt:-Lower end of the frame is tilted

backwards towards the face. In this way optical center

of spectacle lenses coincides with the fixation axis. This

is needed because, most of the time eyes are looking in

downward direction.Pantoscopic tilt reduces chromatic

aberration of a high power lens and has better cosmesis.

Fitting triangle:-is an important criterion of good

fit.Properly fit frames should touch the patient in only

three places – bridge and the top of each ear.An

imaginary line drawn from each point of contact with

the wearer’s face results in an triangular shaped form

and this is called as “Fitting triangle” (Fig. 4).

II SPECTACLE LENSES

Spectacle lenses consist of a transparent material that

has two polished opposing surfaces with ability to focus

light rays in an expected manner.For proper

understanding of the requisite features of lenses, one

needs to be familiar with critical properties like

Fig. 2: Different types of bridges

Fig. 3. Points to be taken into account before dispensingspectable frames

December 2008 B.N. Das - Spectacles 387

refractive index, dispersion expressed by Abbe value

and specific gravity.

Refraction: Bending of light when it passes from one

medium to another.

Power : Power of an ophthalmic lens is determined

by the difference between the front and back curve of

the lenses expressed in dioptre.

Refractive index: is the ratio of velocity of light in

vacuum to the velocity in a given medium at a given

wave length.

Increasing the refractive index reduces the edge

thickness of minus lens and centre thickness of a plus

lens. The volume of the material is reduced and also

we get flatter surfaces.

Specific gravity: is the ratio of the weight of a

substance to the weight of water with the same volume.

A high index lens will be heavier due to high specific

gravity.

Abbe value: indicates the ability of a lens material to

refract white light without chromatic aberration. Abbe

value runs between 1 and 100. Higher the Abbe value

the better but only upto a point. Abbe value of the

human eye is 45,hence it becomes difficult to perceive

above this value. Optimum Abbe value is necessary for

optical efficiency of a lens.

Optical center: of a lens is the position along the

optic axis where no prismatic effect is found.

Visual axis: is an imaginary line from an object of

fixation in the field to the fovea. The best and least

distorted image is obtained when optic centre matches

the visual axis.

A. Types of Spectcle Lenses

a. Can be classified as spheres, cylinders, and prisms.

b. Can be grouped based on choices of lenses.

1. Single Vision

2. Bifocals

3. Lenticular

4. Aspheric

5. Multifocals/Progressives

c.Can be grouped based on the purpose for which they

are given

1. Optical Purposes

2. Sunglasses

3. Vocational Spectacles

- Half eye reading

- Safety spectacles

- Swimming goggles

- Spots glasses

- Driving mask

- Computer glasses

- Welding goggles

- Lorgnette, quizzer

(held before eyes by a handle)

B. Lens Materials

Lenses like frames are made up of a variety of materials.

Common materials:-

Glass, plastics.

Special Materials:

-Poly carbonate

-Hi-index lenses

-Trivex

An ideal ophthalmic lens material should satisfy several

parameters and requirements.

Visual requirement:-Abbe value and other visually

related concerns are to be considered.

Cosmetic:- should be cosmetically acceptable to the

wearer - “People should see the wearer’s eye than the

glasses”.

Safety:-particularly for children, individuals involved

in sports, special jobs and monocular individuals.

Health:-In terms of UV and other occupational

hazards.

Fig. 4. “Fitting Triangle”


1. Glass

Crown glass :-with RI of 1.5223 is used mostly

Abbe value 58.5. They are highly transparent, scratch

resistant and low cost but they are thick, heavy and

can break easily

Flint glass:-has high RI of 1.62. Due to high specific

gravity and low abbe value, flint glass has the

disadvantage of being heavier and has high chromatic

aberration.

2. CR 39 (Columbia resin)

Chemically it is allyl digtycol carbonate and was created

by chemists at Columbia Southern Corporation in 1942.

39 indicates that the 39th test resin produced by the

company was successful

RI 1.498, 1.58, 1.6, 1.74. As it is a thermosetting

material it can be ground and polished after

manufacturing without risk of deformity.

Advantages:-

a. Good optics and chemical resistance.

b. Comfortable due to light weight.

c. Safer than glass lenses.

d. Unlimited designs,coating and tinting.

e. Photo chromatic options available.

Disadvantages:-

a.Poor structural integrity

b.Unstable at high temperature

c.Scratches more easily

d.More expensive

e.Not suitable for rimless frame as they can wreck.

f.Difficult to drill without cracking

3. Polycarbonate Lenses

RI 1.586 is an amorphous material and is the lens of

choice when safety is an issue.

Advantages:-

a. Thinner as they have high refractive Index.Centre

thickness can be ground to 1.2 mm.

b. Lighter (26% Lighter than CR 39) due to low

density.

c. They can bend easily without getting deformed

therefore they have got high impact resistance.

d. Has built in UV protection.

e. Bullet proof.

Disadvantages:-

a. Soft so very low scratch resistance.

b. Tinting not possible.

c. Cause peripheral chromatic aberration in high

minus power.

d. Low abbe value and needs ARC.

It is the lens of choice in children, athletes and people

working in industry.

4. Hi-index Lenses

Are made of denser materials than conventional

materials. They are available in plastic resin(Mitsui

Resin-MR-8, MR-10, MR-11) and glass. They can be

made thinner hence useful in high powers. RI - 1.6,

1.7, 1.8, 1.9. They can be anti reflection coated.

Disadvantages:

a) Not necessarily lighter even though thinner.

b) Costly.

c) Low Abbe value.

d) ARC is a must.

5. Photochromatic Lenses

Has the property to change the colour when the sunlight

or UV light strike the lens surfaces .They are also called

variable tint/Day and Night /Transition lenses.

The darkening process takes as little as 45 seconds but

the reverse lightening process takes up to 20 mts. For

this reason it is not advisable to prescribe them as a

routine.

Photo grey (PG) photo brown (PB), Photopink (PP)

are the available colours. They are available in glass

and plastic. They provide UV protection and some relief

from glare.

6. Trivex (Trilogy) – (Essilor)

This is an alternative to polycarbonate lenses.TRIVEX

material has good optics and inherent UV protection.


Antireflective coating and Scratch resistance coating

can be done. Tinting is possible. It has less chromatic

aberration compared to polycarbonate lenses. They are

the lightest lens available, are unbreakable and resistant

to chemicals. Easy drilling and mounting is possible

hence it is the ideal material for rimless spectacles. Abbe

value of human eyes and Trilogy is 45 which is the

reason for its excellent clarity.

III) LENS ENHANCEMENTS

� UV protection

� Scratch resistance coating (SRC)

� Anti reflection coating (ARC)

� Tinting

� Hydrophobic coating

UV Protection:

In the electromagnetic spectrum we are capable of

seeing wavelengths between 400nm-760nm

(VIBGYOR). Rays above 700 and below 400nm are

harmful to the eyes.

UVC (250-286), are filtered by Ozone layer of earth

UVB (286-320nm) are primarily absorbed by cornea

and can lead to snow blindness, photokeratitis etc,

UVA (320-40nm) are absorbed by crystalline lens and

cause cataract.

Plastic lenses are treated chemically for obtaining UV

protection.

Scratch Resistance Coating (SRC)

Done to prevent easy scratching of plastics. This clear

coating hardens to provide a durable, tougher lens.

Scratch resistant does not mean scratch proof.

Anti Reflection Coating (ARC)

This reduces reflection from the surface of lens and

increase transmission of light. Maximum transmission

gives maximum clarity. This helps to eliminate “shop

window” effect and road blindness (temporary

blindness caused by high beam head lights of oncoming

vehicles). It also reduces eye fatigue in artificially

lit environment. Available in yellow, green and blue

colour.

Hydrophobic Coating:

Is a water resistant coating which prevents staining and

smudging on the lens surface making it easy to clean.

Essilor Crizal Alize and TMC Satin (Titanium Multi

Coating with Satin) are examples of superior ARC with

hydrophobic properties.

Tinting:

Can cut the amount of light that reaches your eyes and

provide relief. Lenses can be tinted in a solid pattern,

meaning entire lens is tinted the same colour or they

can be tinted in a gradient pattern. Several tints like

pink, brown, grey, green, blue etc are available.

Drive Wear Technology: combines ARC,UV

protection and tinting effectively. In addition to glare

and excessive light protection, drive wear enhances red

and green traffic signal recognition. It blocks 100 %

UV light also. They are available as prescriptions for

plano, single vision and as progressives.

IV) Lenses For Correction of Presbyopia

Single vision lenses: Corrects for one focal length.

ie., for distance or near only.

Bifocal lenses – correct vision at two distances ie

Distance and near

Can be kryptok bifocals, or as Univis / D bifocals

Disadvantages : No clear vision for intermediate

distance, has a disturbing dividing line and has “image

jump”.

Progressive Lenses: These are aspheric lenses in

which power gradually changes from distance

Fig. 5. Demonstrates the beneficial effect of anti refractivecoating


correction at the top through intermediate powers to

the near prescription at the bottom of the lens.

Progresssive design

Advantages:

a) No lines in the way of vision

b) Convenience of having a single pair

c) Available in a variety of materials

progressives.It is available in general & customized

designs.

Customized designs- have no preconceived design.

They utilize each patients unique head and eye

movements which are measured using a device called

“Vision Print System” for optimal visual

performance.eg:varilux ipseo, rodenstock pure life, sola-

1etc

Occupational Progressives: are multifocal aspheric

progressives, designed for both near and intermediate

vision. The lower half is for NV correction and upper

half for mid range vision upto 2.5 metres.

They are an ideal solution for CVS as computer users

benefit from a natural head and neck position, and form

a wide intermediate area for computer use.

Eg: AO compact, Zeiss RD, Panorama Mini, Essilor

Ellipse, Kodak Precise

Spectacles for Kids:

- Choose colourful/trendy/sturdy frames

- Not unisex, separate for boys / girls

- Give special attention to frame material, nose bridge,

nose pads, hinges etc. High quality spring

temples,silicone nose pads,elastic straps etc are good

options

- Lens material can be CR39 or Polycarbonate

- Use aspheric design

- Provide SRC, ARC and avoid tinting

- The lens should cover the eyes

Points to be considered in lens fitting:

1. Vertex Distance - Should be specified for higher

prescription.

Pupillary alignment : Pupils should be close to the

optic centre of each lens to take full advantage of

refractive correction given.

2. IPD : Interpupillary distance should be measured

both for distance and near.

3. Fitting plane of lenses – lenses should be in a plane

perpendicular to the visual axis, ideally fitted

15.7mm in front of cornea which corresponds to

Suitable for people who have intermediate

requirements like Computer use, typist etc.

Disadvantages:

a) Peripheral distortion (Swimming & Swaying effects)

b) Narrow field of view

c) Expensive

d) Needs adaptation period

Different companies have come forward with newer

designs which offer wider field of vision & binocular

vision, short corridors, smooth transition and easy

adaptation Eg: Varilux Panamic, Solamax from SOLA,

Concise from KODAK, Internal Progressives from SEIKO,

Progressive Life series from Rodenstock and

Progressives from NOVA.

Internal Progressives are backside progressives –

providing expanded field of vision, wider near vision

and considerable reduction in distortion. Eg; Seiko,

Nova.

Wave front assisted PALs : wavefront analysis used

in LASIK and astronomy is used to detect and eliminate

high order aberrations inherent in conventional

Fig. 6. Progressive lens


anterior principal focus, but practically fitted as

close to the eye as possible.

4. Optical centres: Marking is very important for

proper fitting as it should coincide with visual axis.

Hold the lens against a cross line chart horizontally

or vertically and move until one gets an unbroken

cross

Conclusions

Spectacles still form a major share in optical correction

of refractive errors and presbyopia. Wider choices are

available in frames and lenses. Selection depends on

taste and budget of the patient, occupational condition

and requirement – Finally the wearer should see

well and look good.

References

1. Theory and Practice of Optics & Refraction, AK Khulana

2. Ophthalmic Prescription Work, Arthur G Bennet.

3. Spectacle Glass Technology, Horne DF, Adam Hilger andBristol.

4. Fannin TE & Grosvenor T. Clinical Optics. Aberrationsand Ophthalmic Lens Design.

5. T.B. of Ophthalmology, Vol.I, Optics & Refraction., auser friendly guide. D.Miller, S.Podos, M.Yanoff, 1991.

6. Duke Elder, Practice of Refraction.

7. Optician’s guide-Ajay kumar bhootraFig. 7. Measurement of Interpupillary distance

Fig. 8. Marking of optical centre of the lens


Management of Dislocated PC IOLDr. Meena Chakrabarti MS, Dr. Valsa T. Stephen MS, Dr. Sonia Rani John DNB, Dr. Arup Chakrabarti MS

Inadequate posterior capsular support or zonular

rupture may allow IOL decentration or dislocation.

Decentered IOLs may occur in 0.2 % to 1.2 % of cases

postoperatively 1. The specific cause of the displacement

may not be always evident 1,2.

Various mechanisms include the following

1. Inadequate posterior capsular support due to

posterior capsular rent.

2. Zonular rupture.

3. Accidental placement of IOL through posterior

capsular rent into the anterior vitreous face.

4. Late haptic rotation out of a zone of thin capsular

remnant.

The cause of late spontaneous IOL rotation is

unclear 3,4. It may follow accidental changes in position,

gravitational effect, accidental finger rubbing or other

contact with the eye. Late dislocation of the IOL can

occur spontaneously or following trauma.

Generally posterior chamber IOL placement is safe if

at least 180 degree of the capsular remnant is intact 5.

More extensive support is necessary if the capsular

remnant is missing inferiorly or if the capsular margin

on which the haptics are to be positioned is inadequate.

Indications for subsequent surgery 3,4,5: The

indications for surgical removal include decreased

visual acuity, chronic intraocular inflammation, retinal

detachment and vitreous in the cataract wound

associated with cystoid macular oedema. Although a

dislocated IOL may be well tolerated for a considerable

period of time by some patients, visual rehabilitation

is usually difficult and surgical intervention may become

necessary.

Surgical Technique: For a subluxated IOL 6,7,8

associated with symptoms, surgery may be performed

by a limbal or parsplana approach. In patients with

less extensive subluxation and posterior capsule that is

intact for most of its part, repositioning can be done

via the limbal route, after minimal or no anterior

vitrectomy. However, in the presence of a sizeable

posterior capsular rent, or posterior dislocation of the

IOL into the vitreous cavity, a parsplana approach is

prefered to acheive the goals of surgery 1. A thorough

preoperative assessment of the posterior capsular

integrity is necessary to plan the surgical procedure.

The first step of the procedure is to bring the dislocated

IOL into the anterior vitreous in the plane of the pupil.

Fig. 1. After completion of the vitrectomy, injection of

perfluorocarbon liquid between the retina and theintraocular lens, floats the dislocated intraocular lensoff the retina.

Chakrabarti Eye Care Centre, Kochulloor, Trivandrum - 695 011,


OPH TH A LM I C

S U R G E R Y

December 2008 M. Chakrabarti et al. - Management of Dislocated PC IOL 393

This is achieved after a complete vitrectomy and release

of vitreous adhesions to the IOL. The IOL is then lifted

off the retinal surface using foreign body forceps or

with the help of perflurocarbon liquids (fig 1).

Late spontaneous in - the - bag intra ocular lens and

capsular tension ring dislocation 9,10 has been reported

in pseudoexfoliation syndrome. Capsular tension ring

implantation in “pseudoexfoliation associated zonular

weakness” does not guarantee long term zonular

stability and capsular bag / IOL positions. In these

patients, parsplana vitrectomy, perflurocarbon liquid

injection to lift up the CTR-IOL-CB complex, grasping

this complex with forceps and bringing it to the

pupillary space transfer across pupil, and with a Mc

Phersons forceps the complex can be explanted through

the cornea scleral incision as a single unit.

Alternatively after PFCL injection 11,12, the vitrectomy

cutter is used to cut the capsular bag after supporting

it with an illuminated hook followed by removal of the

CTR and IOL separately through a smaller scleral

tunnel.

Once the PC IOL is in the pupillary plane depending on

the integrity of the capsulozonular remnant there are

three options available to the surgeon. These

include 1,2,

1. IOL repositioning.

2. IOL explanation

3. IOL exchange.

IOL Repositioning: is performed when adequate

capsulo zonular support is present. The lens may be

repositioned without sutures on to the residual posterior

capsule or fixated by sutures to the iris or the sclera.

Surgical success depends on accurate placement of the

haptics into the ciliary sulcus and this requires

visualization of the residual posterior capsule.

In patients with insufficient pupillary dilatation iris

hooks or retractors may be used to allow a more

accurate assessment of the posterior capsule. Since

the use of capsulorhexis has become wide spread,

the peripheral anterior capsule is left intact and

frequently serves as adequate support for the

sulcus fixation of the dislocated PC IOL. Repositioning

of a posterior chamber IOL into the anterior chamber

has also been reported, but this approach is not

recommended due to chronic chafing of the iris by

the IOL.

IOL removal and or exchange options 13 are

usually exercised during surgery when the IOL has been

damaged (e.g. broken haptic), when appropriate

instrumentation to reposit the IOL is unavailable, or

when highly flexible haptics make the IOL unsuitable

for sulcus fixation. IOL exchange may sometimes be

appropriate for plate haptic IOL which are slippery and

difficult to grasp than PMMA lenses. Serrated or

diamond dusted forceps are recommended when

handling these IOLs. Repositioning may be particularly

challenging with silicon plate haptic lenses because they

are extremely floppy and difficult to manipulate. Also,

since they are non expansible and sized for capsular

fixation, centration with sulcus placement may be sub

optimal because it requires a longer dimension.

Implantation of a second IOL without removing the

first IOL has been reported, but this approach is not

generally recommended.

In patients for whom repositioning of posterior chamber

IOLs proves problematic, an intraoperative decision

may be made to remove or replace the lens with an

anterior chamber IOL or a scleral suture-fixated

posterior chamber IOL. Exchanging for a scleral

sutured- IOL has been simplified by new IOL designs

that incorporate positioning holes at the point of

maximum haptic curvature. Alternatively, exchange for

an anterior chamber IOL may be a faster, easier and

less traumatic to the corneal endothelium 14,15,15,17.

Newer AC IOL designs avoid mechanical side effects

that accompanied earlier designs.

Scleral fixated PC IOLs are technically more complex

than AC IOL implants. They carry a high risk of intra

ocular hemorrhage because of penetration of the ciliary

body. The major disadvantage of this technique is that

it leaves a potentially permanent partial thickness fistula

through the sclera, around the 100 prolene suture. This

surgical technique requires a thorough anterior

vitrectomy. IOL power calculation is difficult due to

posteriorly placed optic of the IOL.

It is important to verify the position of the scleral fixated

IOL because 2 prolene sutures are its sole support and

the position of the lens is the most important factor

contributing to post-operative refraction. A one piece,


all PMMA, 100 vaulted, 13.5 mm haptic spread IOL

provides excellent optic centration and haptic

stabilization, when the haptic positioning holes are

placed at the point of greatest haptic spread and one

trans-scleral suture pass per haptic is made. A scleral

entry point 18,19,20 0.50 mm to 0.75 mm from the surgical

limbus avoids the major arterial circle and the entire

ciliary body and provides true ciliary sulcus placement

of the IOL.

Scleral fixation sutures 21,22,23 were first introduced for

implantation of secondary IOLs from the limbal or

parsplana approach or even for placement of a primary

PC IOL in the absence of adequate capsulozonular

support. Although a wide variety of techniques have

been described, all have the following common

objectives:-

1. Proper suture attachments to the IOL haptic.

2. Proper scleral sutures positioned to avoid

torsion,decentration or damage to intraocular

structures.

3. Proper scleral flap sutures to avoid externalization

of the fixation sutures and reduce the risk of

endophthalmitis.

In any scleral suture fixation procedures, the IOL is

first retrieved, then a suture loop is introduced through

the pars plana region into the vitreous cavity and

around the IOL and the suture is firmly secured to the

sclera. The technique that is commonly used for

repositioning the dislocated PC IOL with scleral sutures

in given below 24,25 (Fig. 2)

IOL torsion and decentration can be avoided by accurate

ciliary sulcus placement and adequate excision of bulky

capsular remnant and cortical matter. Histopathological

studies have shown little or no fibrosis around the

a b

c d

Fig. 2 a-d Technique for scleral suture fixation. (2a) Suture isthreaded through a 27-guage straight needle with ahole in the bevel. Needle and suture are introduced

into the vitreous cavity 1mm posterior to the limbusthrough the bed of a partial thickness scleral flap.Slack is created in the suture along the shaft of the

needle by withdrawing it slightly. Under directvisualization the haptic is threaded through the loopalong the shaft of the needle, using an intraocularforceps to grasp the optic. (2b) The needle iswithdrawn, and the suture is tied under the scleral

flap. (2c) Similar procedure is performed for the otherhaptic (2d). Side view of 2c.

Fig. 3. 10-0 prolene suture on an STC6 plus (ethicon) needle.Is passed at 10’o clock, docked on a 30 guage needleat 4’o clock (a) and pulled out with the later diagonally

(b). A Sinskey hook pulls out the suture from superiorcorneo-scleral section. The prolene suture is then tiedto the PC IOL haptic(d). The PC IOL is then delivered

into the posterior chamber with Mc Phersonforseps(e). The sutures are pulled at 4’o clock and10’o clock meridians (f). A single posterior scleral biteis taken and sutures are tied to themselves (g)

a b c

ed

f g

December 2008 M. Chakrabarti et al. - Management of Dislocated PC IOL 395

sutured PC IOL haptics. Therefore, a non dissolving

suture material must be used since it provides the sole

means of support at the ciliary sulcus 24.

Iris fixation sutures 25 requires passing a suture through

the cornea, iris, around the IOL haptic and back through

cornea and iris. Placement of the needle is not accurate

making IOL centration a challenging task. Other

disadvantage includes the increased risk of inviting a

chronic iris mediated intra ocular inflammation 12.

Fig 3 a-g describes the technique of two point scleral

fixator that we have been using for several years and it

has given us predictable results 12,13.

Alternatively a 4 –point scleral fixation can be

performed where the suture passage is made twice,

ensuring adequate anchorage, centration and

eliminating torsion.

Boris Malyugin 26 et al described a technique for

repositioning and trans scleral fixation of a dislocated

plate – haptic foldable collamer posterior chamber

intraocular lens. The displaced IOL was positioned in

the anterior chamber, and a double armed suture or a

curved needle was fixed to the sclera at 10.30 O’ clock

position. The needle then entered the globe and passed

through the superior haptic eyelet of the IOL and was

withdrawn through the scleral wound on the opposite

side. The inferior haptic was fixed at 4.30 and 7.30 o’

clock and provided the mirror reflection of the suture

path of the upper fixed haptic. This technique may be

an useful alternative to lens removal and exchange.

Richard Hoffman 27 et al decribed a technique of scleral

fixation without conjuctival dissection. The scleral

tunnel technique for scleral fixation utilizes a scleral

pocket initiated through a peripheral clear corneal

incision. Full thickness passage of a doubled arm suture

through scleral pocket and conjunctiva with subsequent

retrieval of the suture ends through the external corneal

incision for tying avoids the need for conjunctival

dissection, and a sutured wound closure.

A new technique that relies on glue 28 to implant IOLs

in eyes that lack posterior capsular support was

described by Agarwal et al. They used biological glue

(a quick acting surgical fibrin sealant derived from

human plasma with both hemostatic and adhesive

properties) to perform scleral fixation in a case of

dislocated IOL. Using microrhexis forceps the haptic of

the PMMA non-foldable IOL is grasped and externalized

under the previously prepared scleral flap. Fibrin glue

is applied on the bed of the flap and the flap is closed

in position. In the 12 eyes in their series there were no

notable postoperative complications such as

postoperative inflammation, hyphema, decentration,

glaucoma or corneal oedema on regular follow up.

However a long term follow up is necessary to validate

the efficacy of the procedure.

Surgical Results: The incidence of retinal

detachment following vitrectomy for dislocated PC IOLs

is given in Table 1. In recent series,approximately

70 % of patients achieved a final visual acuity ³

20/40. But surgical series are difficult to compare

accurately due to nonhomogenicity of the variety of

management techniques used.

Table 1. Results of PPV for Dislocated PC IOLs

Study Total RD before RD after Cumulative

(Year) patients PPV PPV

1. Blodi et al 32 4 3 7(1992) (12.5 %) (9.3 %) (21.9 %)

2. Scott 343 25 19 44(2003) (7.3 % ) (5.5 %) (12.8 %)

3. Smiddy 100 4 4 8

(2003) (4.0 %) (4.0 %) (8.0 %)

References

1. W. Smiddy; H. J. Flynn Managing lens fragments anddislocated posterior chamber lenses after CataractSurgery. Focal Points: 1996

2. William E Smiddy; Gonzalo V Ibanez; Eduardo Alfonso;Harry Flynn Surgical Management of dislocatedIOLs.JCRS; Vol 21; Jan 1995, 64-69.

3. Randy V Campo; Kelly D Chung; Ray T Oyakaura. Parsplana vitrectomy in the management of dislocatedposterior chamber lenses. Am. J Ophthalmol; 108;529-534; Nov 1989

4. Harry W Flynn Jr MD; Delyse Buus MD; William WCulbertson MD. Management of Subluxated andPosteriorly Dislocated IOLs using Pars plana VitrectomyInstrumentation. JCRS; Vol 16, Jan 1990; 51-56

5. Flynn H W Jr . Pars Plana Vitrectomy in the managementof subluxated and posteriorly dislocated intra ocularlens. Graefes Arch Clin Exp Ophthalmol 225; 169; 1987

6. Richard J Duffey; Edward J Holland et al. AnatomicStudy of Transsclerally sutured intra ocular lensimplantation.Am. J. Ophthalmol 108; 300-309, Sept1989.

7. Michael Cahane MD; Varda Chen; Issac Avni.Dislocation of scleral fixated PC IOL after fixation sutureremoval . JCRS, Vol 20, March 1994.


8. Fransic W Price, Jr. MD, William E Withson MD. Visualresults of suture fixated PCIOLs during PKP. Oph 96,1989:1234-1240,

9. F.Haken Oner, Nilufer Kocak, Osman Saatis. Dislocationof capsular bag with IOL and capsular tension ring. J.Cataract Refract Surg 2006; 32:1756-1758

10. Schneidermann TE, Johnson MW et al. Surgicalmanagement of dislocated plate haptic IOLs. Am. J.Ophthalmol 1997;123:629-635

11. William E Smiddy, Gonzalo V Ibanez, Edward Alfons,Haerry Hynn. Surgical management of Dislocated IOLs.JCRS.Vol 21, Jan 1995. 64-69.

12. Hilel Lewis. MD; German Sanchez MD. The use of PFCLin the repositioning of posteriorly dislocatedIOLs.Ophthalmol 1993; 100; 1055-1059.

13. Randy .V. Campo, Kelly .D. Chung, Ray. T. Oyakawa. ParsPlana Vitrectomy in the management of posterior chamberlenses. Am.J.Ophthalmol 108, Nov 1989; 529-534.

14. Edward .S. Lim, MD, David .J. Apple MD, Jolie C. TsaiMD et al. An analysis of Flexible Anterior Chamberlenses with special reference to the normalised rate oflens explanation. Ophthalmol 1991, 98: 243-246

15. Tarek.S.Hassen, Kaz Soong, Alan Sugar et al.Implantation of Kelman-Style open loop AC IOLs duringKeratoplasty for aphakic and pseudophakic bullouskeratopathy – A comparison with iris sutured posteriorchamber lenses. Ophthalmol 1991,98:875-880

16. Lawerence .E. Weene MD. Flexible open-loop AC IOLimplants. Ophthalmol 1993, 100, 1636-1639

17. Jonathan .H. Lass, Deana .M. Desentis, Wiliam J.Reinhart. Clinical and morphometric results of PKPwith one piece AC or suture fixted PCIOLs in theabsence of lens capsule. Arch. Ophthalmol 1990,108:1427-1430.

18. Richard .J. Duffey, Edward .J, Holland et al. Anatomicstudy of trans sclerally sutured intraocular lens

implantation. Am. J. Ophthalmol 108, Sept 1989:300-309

19. Surendra Basti, P.C. Tejaswi et al. Outside – inTransscleral fixation for ciliary sulcus IOL placement.JCRS Vol 20, Jan 1994, 89-92.

20. Anthony .J. Lubniewski MD, Edward J Holland MD,Woodford .S. Van Meter MD et al. Histological study ofEye with Trans sclerally sutured posterior chamber IOLs.Am. J. Ophthalmol.110, Sept 1990:237-243

21. Emigdio A Navia- Aray MD. A technique for knotting asuture around the loops of a dislocated IOL within theeye for fixation in the ciliary sulcus. Oph Surgery Oct1993, Vol 24, No:10 :702-707

22. Steven .M. Bloom, Richard .E. Wyszynske Alexander.J. Brucker. Scleral fixation suture for dislocated PCIOLS.Ophthalmic surgery Dec 1990, Vol 21, No:12

23. Martin .S. Arkin, Roger F Stenert. Sutured posteriorchamber intraocular lenses. J Cataract Refract Surg.Dec. 1991, Vol. 21.

24. Kerry Solomon, MD, Joseoh .R. Gussler, Carter Gussler,Woodford S. Van Meter. Incidence and management ofcomplications of transsclerally sutured PCIOLs.J.Cat.Refract Surgery Vol 19, July 1993; 488 -493

25. S.Gregory Smith MD, Wilmengton Deluerare FrankShowden et al. Topographical anatomy of the ciliarysulcus. J. Cataract Refract Surg. Vol 13, Sept 1984:543 -547

26. Boris Malyugin et al. Technique for respositioning andtrans –scleral fixation of a dislocated plate hapticfoldable posterior chamber intraocular lens. J.CataractRefract Surg 2008

27. Richard S Hoffmann, Howard Fine et a .Scleral fixationwithout conjunctival dissection .J.Cataract Refract Surg2006;32:1907-1912

28. Amar Agarwal et al. PCIOL fixed by Fibrin glue. OcularSurg News Europe/ Asia-Pacific Edition March 2008

December 2008 R.H. Trivedi et al. - Pediatric Cataract Surgery 397

Pediatric Cataract SurgeryDr. Rupal H. Trivedi MD MSCR, Dr. M. Edward Wilson MD

Cataract surgery in children remains complex and

demanding. It is quite different from surgery for

cataracts in the elderly. A propensity for increased

postoperative inflammation and capsular opacification,

constantly changing refraction, difficulty in examining

child due to poor compliance, and a tendency to develop

amblyopia are among the factors that make the

management of childhood cataract different from that

in the adult. The aim of pediatric cataract surgery is

not only to provide but also to maintain a clear visual

axis and a focused retinal image.

Preoperative evaluation: A detailed history

including current age, age at onset of symptoms, birth

weight; evidence of maternal infection (especially the

TORCH infections), rash or febrile illness during

pregnancy (may be suggestive of intrauterine infection),

any other prenatal and perinatal history that may be

pertinent (e.g., alcohol, tobacco, drug use, ionizing

radiation during pregnancy), history of ocular trauma

(unless cataract appears to be purely non-traumatic),

ocular status on previous eye examinations (can be

helpful in assessing visual prognosis after treatment),

history of corticosteroid therapy (especially in posterior

subcapsular cataract) and family history (especially for

bilateral cataract) should be documented.

The method of evaluating visual function will vary

according to the age of the child and the level of

cooperation. Documentation of the child’s level of

cooperation with the examination can be useful in

interpreting the results and in making comparisons

among the examinations over time. In infant and

preverbal child the assessment strategy is to determine

whether each eye can fixate on an object, maintain

fixation, and then follow the object into all directions.

The assessment should be performed binocularly and

then monocularly. The force with which the child objects

to alternate occlusion of the eyes is useful to judge the

relative vision in each eye. In an awake and alert child,

if poor fixation and following are noted binocularly after

3-4 months of age, a significant visual loss is suspected.

For strabismic children, an assessment of binocular

fixation pattern is performed in which the examiner

determines the length of time that the non-preferred

eye can hold fixation. It can be reported as, will not

hold fixation with non-preferred eye, holds fixation

briefly with non-preferred eye, or no fixation

preference. With a straight-eyed child and those with

small angle deviation, 20 diopter base-down prism

induced-tropia fixation test can be used to optically

separate the two eyes. Quantitative VA assessment in

cooperative verbal children can be assessed using

optotype VA testing (identifying or matching symbols

or letters), allowing quantification of VA on a Snellen

or preferably, a logMAR scale. Distance VA should be

determined monocularly whenever possible. The fellow

eye should be completely covered (with adhesive

occluder to prevent peeking). In children with posterior

subcapsular cataracts who complain of intolerable glare,

but have good Snellen VA, glare testing should be

performed to evaluate the need for surgery.

The red reflex test can be used to detect the density

and extent of the opacity in the visual axis. Details on

strabismus and nystagmus help when explaining

Department of Ophthalmology, Storm Eye Institute, Miles Center for Pediatric

Ophthalmology, Medical University of South Carolina, Charleston, SC, U.S.A.

The authors have no financial or proprietary interest in any product mentioned

herein. Supported in part by the Grady Lyman Fund of the MUSC Health Sciences

Foundation, Charleston, S.C.

OPHTHALMIC

S U R G E R Y


prognosis to the parents and to prepare them for

patching or further surgeries. Strabismus at

presentation is often an indication that the cataract is

long-standing and that significant amblyopia is likely

to be present. Infants with profound bilateral dense

cataracts develop nystagmus at approximately 3 months

of age because the fixation reflex normally develops

by that time. If manifest nystagmus does develop, the

visual prognosis is worse.

Microphthalmia and poorly dilating pupils increase the

risk of a poor anatomical outcome after cataract surgery.

After dilation, a slit-lamp evaluation should be carried

out if the child is old enough to be cooperative. The

morphology of the cataract may affect prognosis and

give a clue to the etiology. Unilateral PSC should prompt

a careful search for evidence of trauma. Bilateral PSC

cataract may result from chronic uveitis, prolonged

corticosteroid treatment for chronic disease, radiation

treatment for malignancy, or nonaccidental injury (child

abuse). Children with juvenile idiopathic arthritis may

have associated band shaped keratopathy and posterior

synechaie. Lens subluxation, iridodonesis, and aniridia

should be looked for. Total cataract involving the whole

lens can occur in Down syndrome, Type 1 diabetes

mellitus, in congenital rubella (where shaggy nuclear

cataracts are more common), and posterior lentiglobus.

In cases of unilateral cataract, examination of the fellow

eye after pupil dilation is essential to rule out

asymmetric bilateral findings. Anterior lenticonus is

most often associated with Alport syndrome and should

be investigated accordingly. A sudden onset of total

cataract may be an indication of unsuspected trauma,

diabetic cataract or preexisting ruptured anterior

(reported in anterior lenticonus) or posterior capsule

(reported in posterior lentiglobus).

For children approximately above 5-6 years of age,

ability of child to cooperate for slit-lamp examination

is also an indirect indicator that child will cooperate

for YAG-laser capsulotomy if needed. In children above

5-6 years of age with intact posterior capsule and

AcrySofR IOL implantation, visually significant posterior

capsule opacification (PCO) is known to develop after

18-24 months of surgery. If child in this age range seems

to be cooperative for slit-lamp examination during

preoperative evaluation, the surgeon may decide to

leave behind an intact posterior capsule (assuming high

odds of getting child’s cooperation for YAG if needed).

A slit-lamp examination of both parents, if possible,

helps to establish the presence of familial cataracts and

cataract-associated conditions. These findings can be

subtle and the parents may not have been told that

they have any pathology at all.

As compared to unilateral cataract, laboratory

investigation of bilateral cases is more rewarding.

Exhaustive lists of possible laboratory investigations for

a child with cataract can be found in several text books,

however, in an otherwise healthy child, most physicians

do not advise extensive laboratory and genetic

investigations. After detailed evaluation, 86% of

unilateral and 68% of bilateral cataract have no

discernible cause 1. Based on history and examination,

customized laboratory investigations can be advised.

Deciding list of laboratory investigations to detect the

cause can be occasionally based on logistic issues,

financial considerations and parent’s enthusiasm and

willingness to spend time and effort to do so. It is

important to keep in the mind that the common causes

of cataract in children include intrauterine infections,

metabolic disorders, and genetically transmitted

syndromes. Since cataracts can be the presenting sign

of diabetes, children with acquired cataracts of

unknown etiology should be questioned about classic

symptoms of diabetes and evaluation for hyperglycemia

should be performed. Children with Lowe syndrome

have hypotonia, mental retardation, aminoaciduria and

an abnormal facial appearance with frontal bossing,

and chubby cheeks. The lens typically has a reduced

anterior-posterior diameter 2. In addition, these eyes

have frequent association with glaucoma. If Lowe

syndrome is suspected, the urine should be screened

for amino acids. If there is history of maternal rash,

fever, flu-like symptoms, or neonatal physical signs of

intrauterine infection, then acute and convalescent

TORCH titers should be obtained. Developmental

pediatricians and clinical geneticist are experts in

selective investigation based on characteristics of the

child and they should be consulted when appropriate.

Indication for surgery: Indications for cataract

surgery include cataracts obstructing the examiner’s

view for fundus examination in the nondilated pupil

or a blackened retinoscopic reflex preventing refraction

of patient. It is often difficult to decide when to remove


a partial cataract in non-verbal children. The loss of

accommodation after the cataract is removed may

negatively affect visual functioning more than the

partial cataract was. For verbal children, cataract

surgery is contemplated if Snellen VA is 20/50 or worse,

if the child is intolerant to glare or resistant to

amblyopia therapy with gradually deteriorating visual

function. Since a subjective VA cannot be obtained in

infants with cataracts, greater reliance is placed on the

morphology of the cataract; other associated ocular

findings, and the visual behavior of the child, in order

to ascertain whether the cataract is visually significant

or not. The degree of visual impairment induced by

lens opacity differs markedly depending on the location

of the opacity. Generally, the more posterior and more

central location of the opacity is more amblyogenic.

Generally speaking, a cataract that blackens the

retinoscopic reflex for 3mm or more in the center of

the pupil is considered visually significant. If a partial

cataract is being treated conservatively, it is important

to carefully follow these children. Conservative

treatment using mydriatics drops necessitates the

patient’s wearing glasses for reading if any cycloplegic

effect is induced. This has not found widespread

acceptance. Associated glare and loss of accommodation

are the most common obstacles. Visual outcome has

also been unimpressive. Despite these limitations, the

use of mydriatics drops may be kept in reserve in eyes

with slowly progressive cataracts or para-central

cataracts less than 3mm and, especially, in patients for

whom cataract surgery needs to be deferred for any

reason, - be it medical (high risk for anesthesia), social

or economical.

Timing of surgery: Deciding on the appropriate

timing of surgery is most critical during early infancy.

In the case of a unilateral dense cataract diagnosed at

birth, the surgeon can wait until 4-6 weeks of age.

Waiting until this age decreases anesthesia-related

complications and facilitate the surgical procedure.

Waiting beyond this time, however, adversely affects

visual outcome. 3, 4 In the case of a bilateral cataract

diagnosed at birth, a good visual outcome can be

achieved if the child is operated before 10 weeks

of age. 5 The first eye surgery can be offered at 4-6

weeks of age, and the second eye surgery after another

1-2 week’s time. It is important to keep the time interval

to a minimum between the two eye surgeries. For older

children, timing of surgery is not as crucial. In children

beyond the amblyopic age, surgery can often be decided

based on convenience and other logistic issues.

Sequential cataract surgery, more popularly known as

simultaneous bilateral cataract surgery (SBCS), remains

controversial. Almost every discussion on SBCS either

starts or ends with a comment on the disagreement

surrounding its use. The important question is not “can

it be done?” but, more properly, “should it be done?”

Even conservative surgeons, who vote against routine

use of SBCS in children, are more likely to use this

approach when anesthesia poses more than average

risks or the patient lives far away and a visit for surgery

on the second eye would be difficult. In eyes with

penetrating trauma and cataract, primary repair of the

corneal or scleral wound is usually preferred as the

initial step. Cataract surgery with IOL implantation

should be performed 1-4 weeks after a complete

evaluation of damage to intraocular structures (e.g.

posterior capsule rupture, vitreous hemorrhage and

retinal detachment) with ancillary methods such as B-

scan ultrasonography.

Aphakic rehabilitation: For bilateral cataracts,

aphakic glasses and/or contact lens use may be a

reasonable option. However, for unilateral cataracts in

infancy, the issue of when to implant an IOL is

unresolved. We await the results of ongoing multi-

center clinical trial research to help guide us. For

children beyond infancy, IOL implantation is less

controversial. Both IOLs and aphakic contact lenses may

support similar VA after surgery for unilateral cataract

in the presence of good compliance with contact lens.

However, IOLs support better VA when compliance with

contact lens wear is moderate or poor 6.

Intraocular lens implantation in children has the benefit

of reducing dependency on compliance with other

external optical devices (aphakic glasses and contact

lens) and providing at least a partial optical correction.

These are important advantages to the visual

development in amblyopia-prone eyes. However,

concerns about primary IOL implantation are the

technical difficulties of implanting an IOL in the eyes

of children, selecting an appropriate IOL power, and

the risk of visual axis opacification (VAO) after

implantation. Despite performing primary posterior

capsulectomy and vitrectomy, the rate of VAO is higher


in pseudophakic infantile eyes as compared with

aphakic infantile eyes. 7 On the other hand, although it

is possible for an eye with a unilateral infantile cataract

to achieve good visual outcome following contact lens

correction, it has continued to be the exception rather

than the rule.

Parental counseling: Surgeons who perform

pediatric cataract surgery should be prepared for

sometimes a quite lengthy discussion with parents. A

coordinated plan of action can best be developed when

the parents understand the reasons for, goals of, and

the advantages and potential complications of cataract

surgery. When properly informed preoperatively, the

parents and the physician become partners with the

common goal of doing what is best for the child. Time

spent establishing this partnership is not wasted,

because a better informed family is much more likely

to comply with the frequent follow-ups, medications,

patching, glasses wear, etc., that are so essential to the

eventual visual outcome. The parents/caregivers play

a critical role in the postoperative care of the eye and

treatment of amblyopia. They must understand that a

successful visual outcome depends on more than the

surgical procedure; it also depends on their ability to

maintain adequate aphakic correction and follow

through with amblyopia therapy. It is important to

discuss the major pros and cons of the available options

with the parents/legal guardian. Parents should be

made aware that surgery is only one component of the

treatment. Visual prognosis can be explained to the

parent based on preoperative evaluation.

The changing refraction will require frequent follow-

up examinations. Glaucoma is known to develop even

years after cataract surgery. Parents need to understand

that their child may need serial examinations under

anesthesia until the child is cooperative enough to get

examined in the office. The parents should also be

explained about treatment of VAO, strabismus,

glaucoma, and rarely, decentered IOL, synechiolysis,

or removal of a loose stitch. For eyes operated during

early infancy, parents should be made aware that the

first 6-month follow-up is very crucial. Despite

performing primary posterior capsulectomy and

vitrectomy, many infant eyes develop VAO, and most

eyes that develop VAO, develop it in the first six

postoperative months. Earlier detection (and treatment

if needed) can help to achieve a better visual outcome.

For eyes operated with an intact posterior capsule,

parents should be made aware that the child would

require a secondary procedure for PCO. Parents of

children with lens implants are also made aware that

glasses will likely still be needed postoperatively even

when an IOL is implanted. In addition, glasses power

may need to be changed frequently after surgery,

because of changing refraction. Useful web resources

for parents: http://www.pgcfa.org/cataract.htm and

http://www.ich.ucl.ac.uk/factsheets/families/

F020023/ (information for families with cataract).

Examination under anesthesia: We routinely

perform an EUA during the same session as the cataract

surgery. However, to do an EUA as a separate session is

also an acceptable approach. Intraocular pressure

should be checked as soon as possible after induction

of anesthesia. Although we routinely use the tonopen,

if in doubt, we recheck IOP using the Perkins tonometer.

In addition to high IOP, a difference of IOP between

the two eyes is alarming. Cataracts and glaucoma are

associated with congenital rubella and Lowe Syndrome.

The next step for us is to take keratometry

measurements. We use the Nidek handheld

keratometer. However, many other centers uses an

autorefractokeratometer for this purpose. The

remaining examinations listed below can be performed

in any chronology: examine the eye using the operating

microscope, immersion A-scan ultrasound for globe

axial length, horizontal corneal diameter, retinoscopy

(if possible), and fundus examination. Some physicians

use a slit lamp attachment to operating microscope for

evaluating location of the cataract. Immersion A-scan

performed by a skilled ultrasonographer helps to reduce

the incidence of postoperative refractive surprises. A

shorter or longer axial length in the eye with the

cataract can be sign of poor prognosis. In the case of

no view on fundus examination, we perform a B-scan

ultrasound examination. Although it is often not

possible to do a preoperative cycloplegic refraction of

an eye with a dense cataract, an uninvolved or less

involved fellow eye should be refracted. The presence

of refractive error in the fellow eye may help when

deciding on an IOL power.

Preoperative and Intraoperative Medications:

It is important to apply antibiotic drops to the eye prior


to beginning surgery. We begin topical application of

antibiotics approximately 1 hour prior to surgery. The

drop is given every five minutes for a total of four times.

While it would be ideal to start the antibiotic earlier

than 1 hour before surgery, it is logistically difficult.

Dilating drops are also given preoperatively on check-

in every five minutes times three. We make up a peds

combination drop that consists of 2 mL 2 %

cyclopentalate, 0.5 mL 10 % phenylephrine, and 0.5

mL 1 % tropicamide in every 3 mL of drops. In essence,

each drop delivered to the patient contains 1.3 %

cyclopentalate, 1.67 % phenylephrine, and 0.17 %

tropicamide. To aid in maintaining dilation of the pupil

throughout surgery, 0.5 mL epinephrine 1:1000 solution

is added to each 500 mL bottle of irrigating solution.

We recently published a pediatric case of intraoperative

floppy iris syndrome IFIS in one eye and no IFIS in the

other eye as a result of the inadvertent absence of

epinephrine in the irrigating fluid of the eye

demonstrating signs of IFIS 8. We strongly recommend

epinephrine in the irrigation fluid for all pediatric

cataract surgeries. Povidone iodine, diluted to a 5 %

solution, is applied to the eye at the end of the surgical

skin and lash prep. An additional drop is placed at the

conclusion of surgery.

Surgical Steps:

Incision: Pediatric cataracts can be removed through

a relatively small wound, as the lens has no hard

nucleus. Therefore, wounds should be constructed to

provide a snug fit for the instruments that pass into

the anterior chamber. When an IOL is not being

implanted, two stab incisions are usually made at or

near the limbus. These incisions should not be larger

than necessary for the instruments being used. For

instance, a micro vitreoretinal (MVR) blade can be used

that creates a 20-gauge opening for a 20-gauge

vitrector/aspirator to enter the anterior chamber. A 20

gauge blunt tipped irrigating cannula can also be used

through a separate MVR blade stab incision. If the

instrument positions need to be reversed, the snug fit

is maintained. If 23 gauge or 25 gauge instruments are

used, an MVR for that gauge opening can be utilized.

While some surgeons prefer phaco-aspiration

(aspiration utilizing a standard phacoemulsification

hand-piece), bimanual technique using an irrigating

hand-piece and a separate aspiration hand-piece is

preferred by the authors. Anterior chamber stability is

maintained by limiting wound leak and using a high

irrigation setting. When a foldable IOL is being

implanted, a corneal tunnel is preferred since it leaves

the conjunctiva undisturbed. In infants, a scleral tunnel

is sometimes used because it heals more transparently

than a corneal tunnel. In addition, a rigid IOL is

implanted occasionally when sulcus placement over a

large pre-existing posterior capsulotomy is desired. In

these instances, a scleral tunnel is utilized.

Unlike adults, corneal incisions do not usually self-seal

in children. Our 2001 survey indicated that only 20%

and 3 % of the American Society of Cataract and

Refractive Surgeons (ASCRS) and American Association

for Pediatric Ophthalmology and Strabismus (AAPOS)

respondees, respectively, left both tunnel and

paracentesis incisions unsutured. 9 According to one

study 10, self-sealing wounds failed to remain watertight

in children below 11 years of age, especially when an

anterior vitrectomy was combined with cataract

extraction. Even in older children, suturing is

recommended since postoperative eye rubbing is

common. The recommended closure material is a 10-0

synthetic absorbable suture. The use of non-absorbable

sutures occasionally calls for an EUA for suture removal.

Even when economic issues are a deciding factor in

choice of suture material, it is better to use absorbable

sutures rather than subject the child to additional

anesthesia.

Anterior Capsulotomy: The anterior capsule in

children is highly elastic and poses challenges in the

creation of the capsulotomy 11, 12, 13 While a manual

continuous curvilinear capsulorhexis (CCC) is ideal for

adults, it is more difficult to perform in young eyes.

When performing a manual CCC in a child, the

following technical recommendations are offered. Use

of a highly viscous ophthalmic-viscosurgical-device

(OVD) is recommended to fill the anterior chamber and

flatten the anterior capsule. A slack anterior capsule

will be easier to tear in a controlled fashion. Re-grasp

the capsulorhexis edge frequently and begin with a

smaller capsulotomy than desired. Because of the

elasticity, the opening will be larger than it appears

once the capsular flap is released. In order to control

the turning of the CCC edge along a circular path, the


tear must often be directed more toward the center of

the pupil than would be necessary in an adult eye. If

the capsule begins to extend peripherally, stop before

the edge is out of sight under the iris. Re-grasp the

capsule edge and pull directly toward the center of the

pupil to recover the tear. Converting to a vitrectorhexis

or a radio frequency diathermy capsulotomy may also

be warranted. Using small incision capsulorhexis

forceps that fits easily through a paracentesis will allow

conversion to vitrector instruments when needed

without leakage around the vitrector hand-piece during

use. While a CCC using the techniques described above

is a reasonable option beyond age 4, it will be more

difficult when attempted on children aged 4 and

younger. The vitrectorhexis is an alternative anterior

capsulotomy method that will be more consistently

successful than manual CCC in the youngest patients.

When creating a vitrectorhexis, the following surgical

caveats are offered. Use a vitrector supported by a

Venturi pump, if possible. A bi-manual technique with

a separate infusion port is recommended. Maintain a

snug fit of the instruments in the incisions through

which they are placed. The anterior chamber of these

soft eyes will collapse readily if leakage occurs around

the instruments, making the vitrectorhexis more

difficult to complete. A MVR blade can be used to enter

the eye. The vitrector and a blunt-tip irrigating cannula

fit snugly into the MVR openings. We recommend either

a 20 gauge Grieshaber irrigation handpiece (Alcon) or

a Nichamin cannula (Storz). An anterior chamber

maintainer can also be used if the surgeon prefers. We

have found that it is not necessary to begin the

capsulotomy with a bent-needle cystotome. Merely

place the vitrector, with its cutting port positioned

posteriorly, in contact with the center of the intact

anterior capsule. Turn the cutter on and increase the

suction using the foot pedal until the capsule is engaged

and opened. A cutting rate of 150 to 300 cuts per minute

and an aspiration maximum of 150 to 250 are

recommended. These settings are for currently utilized

Venturi-pump machines. Adjustments may be needed

for other machines. With the cutting port facing down

against the capsule, engage the capsule and enlarge

the round capsular opening in a spiral fashion to the

desired shape and size. Any lens cortex that escapes

into the anterior chamber during the vitrectorhexis is

aspirated easily without interrupting the capsulotomy

technique. Care should be taken to avoid leaving any

right-angle edges, which could predispose to radial tear

formation. A third option for creating an anterior

capsulotomy in a child is available with the use of high

frequency endodiathermy (Kloti radio frequency

endodiathermy). This instrument cuts capsule

efficiently but results in an edge that tears easily if

stretched. The Fugo plasma blade has also been used

to make an anterior capsulotomy. Our experience with

the Fugo blade in children is only a few cases, but the

capsulotomy edge created in those cases was not very

different clinically from that produced by the Kloti

instrument mentioned above. Use of capsular dyes has

started attracting pediatric cataract surgeons, also.

Visualization of the capsular flap is important to

maintain control of any tears and to ensure that the

edge is continuous. A report from the American

Academy of Ophthalmology 14 has concluded that “it is

reasonable to consider the use of dye in cataract surgery

in cases in which inadequate capsule visualization or

inexperience with capsule visualization may

compromise the outcome. The use of dye in routine

cases cannot be recommended until a lack of toxicity is

more clearly demonstrated in the event of longer

duration exposure or posterior segment exposure”. Both

trypan blue and indocyanine green dyes provide

excellent visualization of the anterior capsule flap

during CCC. When injecting under air, the dye should

be injected after the paracentesis, but prior to creating

the main incision, to help with anterior chamber

stability. Staining under air versus under OVD was

reported similar efficacy and safety. In addition to better

visualization, trypan blue has been reported to

minimize epithelial cell proliferation in pediatric

cataract surgery. The staining the anterior capsule with

trypan blue affected the density and viability of

LECs. 15 The use of dyes is not advised when using

hydrophilic IOLs, to avoid permanent discoloration of

the IOL. 16

Lens substance aspiration (Phacoaspiration):

Thorough removal of lens substance is especially crucial

for pediatric eyes. When any cortical matter, which

clinically may resemble a harmless strand or fiber, is

left behind, it actually leaves behind a large number of

mitotically active cells. These cells have the potential

to grow and cause a proliferative form of VAO. The


best means of reducing the incidence of this is to remove

as many of these cells as possible at the time of surgery.

Since VAO is one of the most frequent postoperative

complications in pediatric cataract surgery, meticulous

removal of the lens substance is a crucial step in the

management of pediatric cataracts. Pediatric cataracts

are soft but they may be “gummy.” Phacoemulsification

is not needed. Lens cortex and nucleus can be aspirated

in every case with an irrigation/aspiration or vitrectomy

hand-piece. We prefer the bimanual approach using

separate irrigation and aspiration. Separate irrigation

and aspiration help maintain the anterior chamber

stability, decrease fluctuations of the anterior chamber

and help thorough removal of lens substance. When

using the vitrector, bursts of cutting can be used

intermittently to facilitate the aspiration of the more

“gummy” cortex of young children. The advantage of

using the vitrector is that it is possible to perform

vitrectorhexis, irrigation/aspiration, posterior

capsulectomy and vitrectomy – all with one instrument

(the setting needs to be changed appropriately). This

avoids extra manipulation and repeated entry into and

exit from the eye. In older children, after a manual

CCC we prefer 20-gauge bimanual irrigation/aspiration

hand-pieces that are tapered and curved (Alcon/

Grieshaber 170-01 for irrigation and Alcon/Grieshaber

170-02 for aspiration). Maintenance of the anterior

chamber is critical when removing lens substance.

Aspiration of fluid from the anterior chamber must be

balanced by adequate infusion. Although we do not

have personal experience of using heparin sodium in

the irrigating fluid, reports showing a beneficial role in

preventing postoperative inflammation have appeared

in the literature. 17 The use of heparin should be avoided

in eyes with a compromised blood-aqueous barrier (e.g.,

previous ocular surgery) as they are at high risk of

developing postoperative hyphema.

Hydrodissection has been thought to be less useful in

children than in adults. However, one study has shown

the intraoperative benefits of performing multiquadrant

hydrodissection. 18 The potential benefits are an overall

reduction in the operative time and a reduction in the

amount of irrigating solution used to facilitate lens

substance removal. A fluid wave can sometimes be

generated in older children but not reliably in infants

and toddlers. Cortical material strips easily from the

pediatric capsule even in the absence of hydrodissection

if the proper technique is used. Hydrodissection should

not be done in children with posterior polar cataracts

in children because of the fragility in the posterior

capsule in these cases.

Posterior Capsulectomy and Vitrectomy: In

young children who undergo pediatric cataract surgery,

PCO is rapid and virtually inevitable if the posterior

capsule is left intact. 19-22 PCO occurs much faster and

is much more amblyogenic in younger children as

compared with older children. The advent of vitreous

suction cutting devices for removing the center of the

posterior capsule and a portion of the anterior vitreous

during the initial surgery in young children undergoing

cataract surgery dramatically decreased the need for

secondary surgery. A primary posterior capsulectomy

and anterior vitrectomy during IOL implantation in the

pediatric cataract gives the best chance for maintaining

a long-term clear visual axis. Nd: YAG laser posterior

capsulotomies are usually necessary in children when

the posterior capsule is left intact. Larger amounts of

laser energy are often needed as compared to adults,

and the posterior capsule opening may close, requiring

repeated laser treatments or a secondary pars plana

membranectomy. At present primary posterior

capsulectomy and anterior vitrectomy is common

practice while managing younger children with

cataract. An important question that remains is, when

should the posterior capsule be left intact? We answer

this question looking at several factors (age, association

of posterior capsule plaque or defect, availability of YAG

laser, expected cooperation of child approximately 12-

24 months after cataract surgery for YAG). As a rough

guideline, in children below 5 years of age, we prefer

to do primary posterior capsulectomy and vitrectomy.

In children, 5-8 years of age, we will do a posterior

capsulectomy with or without vitrectomy, as needed.

In children above 8 years of age, we keep an intact

posterior capsule more often. Anterior segment

surgeons are often more accustomed to, and more

comfortable with, a limbal (or anterior) approach. Our

current strategy is to perform these procedures via the

pars plana/plicata preferentially, whenever we intend

to use a primary vitrectomy in pediatric eyes receiving

IOL implantation. The size of the posterior capsule

opening should be large enough to help avoid VAO,

but small enough that sufficient peripheral capsular

support remains for capsular fixation of an IOL. Even


if the surgeon is not planning to implant an IOL in a

specific eye, it is important to leave behind sufficient

anterior and posterior capsular support at the time of

cataract surgery to facilitate subsequent in-the-bag or

sulcus-fixated IOL implantation (if needed). 23 Ideally,

the surgeon should aim for a central, circular opening

in the posterior capsule about 1-1.5 mm smaller than

the IOL optic. On the Accurus machine (Alcon

Laboratories, Fort Worth, Texas), an irrigation rate of

30+ cc/min and a cutting rate of 600 cuts/min have

proven effective at our setting. Readers should follow

the manufacturer’s instruction manual for using a

specific machine and setting. When the pars plana/

plicata approach is chosen, the IOL should be inserted

into the capsular bag using OVD, while the posterior

capsule is still intact. The OVD can be removed without

fear of engaging vitreous, because removal precedes

the posterior capsulectomy. While the irrigation cannula

remains in the anterior chamber, a MVR blade is used

to enter the pars plana/plicata 2-3 mm (2-mm in

patients less than 1-year old, 2.5-mm in patients 1-4

years old, and 3-mm in patients over 4 years old)

posterior to the limbus. The vitrector is then inserted

through this incision and used to open the center of

the posterior capsule. The endpoint for the vitrectomy

is difficult to define. Sufficient vitreous should be

removed centrally so that the LEC cannot use the

vitreous face as a scaffold for VAO. Any vitreous that

tracks forward past the plane of the posterior

capsulectomy needs to be removed. VAO after primary

posterior capsulectomy and vitrectomy is often blamed

on an inadequate posterior capsule opening or an

inadequate vitrectomy. These assertions have not been

verified scientifically. In cataract with associated blood

vessel anomalies, such as persistent fetal vasculature,

vitrectomy instrumentation is used to remove the

posterior lens capsule, abnormal membrane, and

anterior vitreous. Intraocular scissors and intraocular

cautery are also used as needed. Intracameral

triamcinolone (Kenalog) may have a potential benefit

in the management of pediatric cataract. Kenalog

injection into the anterior chamber provides the anterior

segment surgeon a means to localize and identify if

any vitreous strands remaining in anterior chamber that

otherwise might have gone unnoticed. Sutureless, pars

plana vitrectomy through self-sealing sclerotomies has

been reported in the literature. No difference in the

amount of visible vitreous incarceration between

sutured and sutureless sclerotomies was reported, using

ultrabiomicroscopy. However, wound leakage,

extension, dehiscence, hemorrhage, vitreous and/or

retinal incarceration, retinal tear and dialysis have been

reported with this technique. Difficulty with the passage

of instruments has also been observed when tunnel

incisions are used.

IOL implantation: A general consensus exists that

IOL implantation is appropriate for most older children

undergoing cataract surgery. In contrast, the advisability

of IOL implantation during the first year of life is still

being questioned. 24 We showed a nearly 5-fold increase

in the number of the ASCRS respondents and more

than a 13-fold increase in the number of the AAPOS

respondents implanting IOLs in children 2-years old

and younger from 1993 to 2001. It is well known that

the majority of the eye’s axial growth occurs during

the first two years of life. This rapid eye growth makes

selection of an IOL power for an infant difficult.

Selecting the best IOL power to implant in a growing

child presents unique challenges. While Gordon and

Donzis 25 have documented the axial growth pattern of

normal eyes in children, the axial growth of cataractous

eyes is different. 26 In the normal phakic child, there is

little change in refraction (0.9 diopters from birth

through adulthood on average) because the power of

the natural lens decreases dramatically as the eye grows

axially. However, an IOL placed in a child’s eye cannot

change in power to match the growth of the eye. An

IOL chosen for emmetropia in early childhood is likely

to leave the patient highly myopic in adulthood. For

children beyond age 2, studies are available to help

the surgeon predict average growth of the eye. When

operating on children, many surgeons have advised

selecting an IOL power that will leave mild to moderate

hyperopia, leaving less hyperopia with increasing age.

Details on IOL power selection has been provided in

earlier issue of this journal.

When placing an IOL in a child’s eye, in-the-bag

implantation is strongly recommended. Care should be

taken to avoid asymmetrical fixation with one haptic

in the capsular bag and the other in the ciliary sulcus.

This can lead to decentration of the IOL. In contrast to

adults, dialing of an IOL into the capsular bag can be

difficult in children. Often the IOL will dial out of the


capsular bag rather than into it. This tendency can be

blunted somewhat by the use of highly viscous OVDs.

Foldable hydrophobic acrylic IOLs are used increasingly

in children. The AcrySof® hydrophobic acrylic IOL

(Alcon Laboratories, Ft. Worth, Texas) has been shown

to be very biocompatible for the pediatric eyes. 27

Tassignon and colleagues 28 reported the outcome of a

surgical procedure they called “bag-in-the-lens” in eyes

with pediatric cataract. In this technique, the anterior

and posterior capsules are placed in the groove of a

specially designed IOL after a capsulorhexis of the same

size is created in both capsules. The authors reported a

clear visual axis in all pediatric patients with an average

follow-up of 17-months.

The ongoing development in adjustable IOL technology

may prove very useful in the future of the surgical

management of pediatric cataracts. The possibility of a

lens that could be adjusted to counter the myopia

induced by ocular growth is potentially exciting. An

ideal pediatric adjustable IOL implant should be

biocompatible, allow for safe repeatable adjustment

procedures performed at any time after cataract

surgery; and have an adequate refractive error

adjustment range. As of today, this ideal adjustable IOL

does not exist. However, the concept of such and IOL

is being developed and after certain modifications, such

an IOL may become available.

Each of the multifocal IOLs represents a compromise

based upon the simultaneous vision principle. Two or

more images are formed on the retina at the same time,

one image at near and the other at distance focus. The

brain selects the image it wants to see. Some loss of

contrast is inherent to simultaneous vision since the

available light is split between the near focus and the

distance focus. Uncorrected refractive error (cylinder

of more than 1 diopter or the changes in sphere that

occur with eye growth) may result in more significant

blur because of the simultaneous vision concept.

Alternating vision, which is provided by a monofocal

IOL and bifocal glasses, results in only one object being

in focus at a time and all incoming light is directed to

this focus. While the increased use of multifocal and

accommodative IOLs for implantation during the

teenage years is predictable, we would caution surgeons

that these lenses may not be advantageous in growing

or amblyopic eyes. With residual refractive error,

especially the myopia that develops after eye growth,

multifocality may (ironically) result in more spectacle

dependence compared to a monofocal IOL with residual

myopia. This deserves further study.

The vast majority of children undergoing secondary IOL

implantation have had a primary posterior capsulotomy

and anterior vitrectomy. If adequate peripheral capsular

support is present, the IOL is placed into the ciliary

sulcus or in the reopened capsular bag. Viscodissection

and meticulous clearing of all posterior synechiae

between the iris and the residual capsule is mandatory.

The most common IOL used in secondary implantation

is the 3-piece AcrySof® IOL. However, decentrations

can occur, especially in eyes with large anterior

segments and axial length measurements greater than

23 mm. When inadequate capsular support is present

for sulcus fixation in a child, implantation of an IOL is

not recommended unless every contact lens and

spectacle option has been explored fully. Anterior

chamber IOLs and scleral or iris-fixated posterior

chamber IOLs are used in children when other viable

options are absent but the long-term consequences of

these placements are unknown.

Postoperative medications and Follow-up: A

drop of dilute (5 %) Povidone iodine should be placed

on the operative eye immediately after surgery. An

antibiotic steroid and atropine ointment should be

placed. A patch and Fox shield are placed over the eye.

We prefer to secure the shield with 2 Tegaderm sheets

instead of standard tape. The patch and shield should

remain on the eye until the morning after surgery. We

remove it in the office, examine the eye and show the

parents how to apply the postoperative drops. There

are some variances from the protocol in certain

situations. With older children, the atropine may be

deleted. Babies who are left aphakic do not receive the

ointment. We use topical drops for these eyes, and

rather than patching the eye, we apply a Silsoft contact

lens (usually a 7.5 base-curve and +32 D or +29 D

power) at the end of surgery. The parents can then begin

the drops right away. For older children (above age 6-

7 years), the parents are allowed to remove the patch

and shield 4-5 hours after the surgery and begin the

postoperative drops. The eye is still examined on the

first postoperative day. Topical atropine (0.5% in

children less than 1 year of age, and 1% thereafter) is


utilized once per day for 2 - 4 weeks in children up to

age 6 years. Topical steroid is used topically 6 times

per day for 2 weeks and then 3 - 4 times per day for an

additional 2 weeks. An antibiotic drop (the same

fluoroquinolone used pre-operatively) is used for one

week after surgery. Any residual refractive error is

corrected after the wound stabilizes and the synthetic

absorbable sutures dissolve. We rarely use oral steroids

except in some uveitis patients or some trauma cases.

We schedule postoperative examinations at 1 week, 4

weeks, 3 months, and 6 months postoperatively. We

also consider a yearly EUA in order to measure

intraocular pressure, examine the peripheral retina,

monitor eye growth using A-scan ultrasound and

examine the position of the IOL and detect any

secondary membrane or after-cataract formation. Once

children become old enough and cooperative enough

to undergo these examinations awake, the yearly EUA

becomes unnecessary.

In summary, pediatric cataract surgery is a complex

issue best left to surgeons that are familiar with its long-

term complications and lengthy follow-up. Cataract

surgery in children is the first stepping-stone in the long

road to visual rehabilitation, not the end of the journey.

Consideration of a clear visual axis and corrected

refractive error are very important to the visual outcome

of children as they grow and develop. Postoperative

complications may develop in the early postoperative

period, or after many years, making it crucial to follow

these children closely on a long-term basis after

pediatric cataract surgery. Management of residual

refractive error, amblyopia, and strabismus must be

customized to each child based on measurements that

can be a challenge to obtain, and which can change

over time. Despite these uncertainties, diligent

teamwork involving the physician and the parents can

result in a gratifying outcome for the long-life of the

child.

References

1. Johar SR, Savalia NK, Vasavada AR, Gupta PD.Epidemiology based etiological study of pediatriccataract in western India. Indian J Med Sci. 2004Mar;58(3):115-21.

2. Tripathi RC, Cibis GW, Tripathi BJ. Pathogenesis ofcataracts in patients with Lowe’s syndrome.

Ophthalmology. 1986;93(8):1046-51.

3. Birch EE, Stager DR. The critical period for surgical

treatment of dense congenital unilateral cataract. Invest

Ophthalmol Vis Sci. 1996;37(8):1532-8.

4. Wilson ME, Jr., Trivedi RH, Hoxie JP, Bartholomew LR.

Treatment outcomes of congenital monocular cataracts:

the effects of surgical timing and patching compliance.

Journal of Pediatric Ophthalmology & Strabismus.

2003;40(6):323-9.

5. Lambert SR, Lynn MJ, Reeves R, Plager DA, Buckley

EG, Wilson ME. Is there a latent period for the surgical

treatment of children with dense bilateral congenital

cataracts? J AAPOS. 2006;10(1):30-6.

6. Birch EE, Cheng C, Stager DR, Jr., Felius J. Visual acuity

development after the implantation of unilateral

intraocular lenses in infants and young children. J

AAPOS. 2005;9(6):527-32.

7. Lambert SR, Lynn M, Drews-Botsch C, Loupe D, Plager

DA, Medow NB, et al. A comparison of grating visual

acuity, strabismus, and reoperation outcomes among

children with aphakia and pseudophakia after unilateral

cataract surgery during the first six months of life. J

AAPOS. 2001 Apr;5(2):70-5.

8. Wilson ME, Trivedi RH, Mistr S. Pediatric intraoperative

floppy-iris syndrome. J Cataract Refract Surg.

2007;33(7):1325-7.

9. Wilson ME, Jr., Bartholomew LR, Trivedi RH. Pediatric

cataract surgery and intraocular lens implantation:

practice styles and preferences of the 2001 ASCRS and

AAPOS memberships. J Cataract Refract Surg.

2003;29(9):1811-20.

10. Basti S, Krishnamachary M, Gupta S. Results of

sutureless wound construction in children undergoing

cataract extraction. Journal of Pediatric Ophthalmology

& Strabismus. 1996;33(1):52-4.

11. Trivedi RH, Wilson ME, Jr., Bartholomew LR.

Extensibility and scanning electron microscopy

evaluation of 5 pediatric anterior capsulotomy

techniques in a porcine model. Journal of Cataract &

Refractive Surgery. 2006;32(7):1206-13.

12. Wilson ME, Jr., Trivedi RH, Bartholomew LR, Pershing

S. Comparison of anterior vitrectorhexis and continuous

curvilinear capsulorhexis in pediatric cataract and

intraocular lens implantation surgery: a 10-year

analysis. J AAPOS. 2007 Oct;11(5):443-6.

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pediatric cataract surgery. Trans Am Ophthalmol Soc.

2004;102:391-422.

14. Jacobs DS, Cox TA, Wagoner MD, Ariyasu RG, Karp CL,

American Academy of O, et al. Capsule staining as an

adjunct to cataract surgery: a report from the American

Academy of Ophthalmology. Ophthalmology.

2006;113(4):707-13.

15. Nanavaty MA, Johar K, Sivasankaran MA, Vasavada AR,

Praveen MR, Zetterstrom C. Effect of trypan blue

staining on the density and viability of lens epithelial

cells in white cataract. J Cataract Refract Surg.

2006;32(9):1483-8.


16. Werner L, Apple DJ, Crema AS, Izak AM, Pandey SK,Trivedi RH, et al. Permanent blue discoloration of ahydrogel intraocular lens by intraoperative trypan blue.J Cataract Refract Surg. 2002 Jul;28(7):1279-86.

17. Wilson ME, Jr., Trivedi RH. Low molecular-weightheparin in the intraocular irrigating solution in pediatriccataract and intraocular lens surgery. Am J Ophthalmol.2006;141(3):537-8.

18. Vasavada AR, Trivedi RH, Apple DJ, Ram J, Werner L.Randomized, clinical trial of multiquadranthydrodissection in pediatric cataract surgery. Am JOphthalmol. 2003;135(1):84-8.

19. Vasavada AR, Trivedi RH, Singh R. Necessity ofvitrectomy when optic capture is performed in childrenolder than 5 years. Journal of Cataract & RefractiveSurgery. 2001;27(8):1185-93.

20. Vasavada AR, Trivedi RH, Nath V. AcrySof intraocularlens implantation in children. J Cataract Refract Surg.2004;In press.

21. Vasavada AR, Trivedi RH, Nath V. Visual axis opacificationafter AcrySof intraocular lens implantation in children.J Cataract Refract Surg. 2004;30(5):1073-81.

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children. J Cataract Refract Surg. 2000;26(6):824-31.

23. Trivedi RH, Wilson ME, Jr., Facciani J. Secondaryintraocular lens implantation for pediatric aphakia. JAAPOS. 2005;9(4):346-52.

24. Trivedi RH, Wilson Jr ME, Bartholomew LR, Lal G,Peterseim MM. Opacification of the visual axis aftercataract surgery and single acrylic intraocular lensimplantation in the first year-of-life. J AAPOS.2004;8:156-64.

25. Gordon RA, Donzis PB. Refractive development of thehuman eye. Arch Ophthalmol. 1985;103(6):785-9.

26. Trivedi RH, Wilson ME. Biometry data from caucasianand african-american cataractous pediatric eyes.Investigative Ophthalmology & Visual Science.2007;48(10):4671-8.

27. Wilson ME, Jr., Trivedi RH, Buckley EG, Granet DB,Lambert SR, Plager DA, et al. ASCRS white paper.Hydrophobic acrylic intraocular lenses in children. JCataract Refract Surg. 2007 Nov;33(11):1966-73.

28. Tassignon MJ, De Veuster I, Godts D, Kosec D, Van denDooren K, Gobin L. Bag-in-the-lens intraocular lensimplantation in the pediatric eye. J Cataract RefractSurg. 2007;33(4):611-7.


Investigations in Microbial KeratitisDr. Jyothi P T MS

Microbial keratitis is a common cause of ocular

morbidity and blindness. Different types of bacteria,

virus, fungus, parasites can invade the cornea if the

normal corneal defense mechanism is compromised.

Although some keratitis have very distinctive

appearance, it is not easy to identify the responsible

organisms based on the morphological appearance of

the corneal lesion alone. Since the clinical appearance

of infective keratitis may sometimes be misleading

(eg. A ring infiltrate can be caused by fungus,

acanthamoeba, herpes simplex or even pseudomonas),

laboratory investigations are often required for

identifying the causative organisms.

Different steps in the microbiological diagnosis of

Corneal infections are

1) Proper specimen collection

2) Direct microscopic examination of the smear

3) Innoculation of material into various culture media

and isolation of organisms

4) Demonstration of antigen and antibodies.

Proper Specimen collection

The technique of proper specimen collection is very

important in the recovery of organisms. This can be

done under slit lamp biomicroscope or by using a simple

magnification device with the patient lying supine.

Sterile precaution should be taken to avoid

contamination. Proparacaine 0.5 % is the ideal local

anaesthetic since it has the least inhibitory effect on

organism recovery. Scrapings should be taken from the

edges and base of the ulcer using blunt spatula, No. 15

Bard Parker blade or hypodermic needle.(Fig 1) All

overlying loose material should be removed before

scraping. The scraped material is smeared on to glass

slide and inoculated into the culture media. Deep

stromal lesions and progressive lesions with initial

negative cultures may require corneal biopsy to obtain

adequate specimen.

Department of Ophthalmology, Calicut Medical College

Corneal scrapings not only provides material for

microbiologic diagnosis, but also debrides the necrotic

tissues and enhances antibiotic penetration.Other than

corneal scrapings, contact lens case and solutions,F.B’s

on the cornea, corneal biopsy specimen and corneal

button after keratoplasty are some of the useful samples

for microbiological examinations in certain situations.

Direct microscopic examination

Direct microscopic examination of smear is important

because it help us to determine the type of organism

(whether bacteria, fungus, acanthamoeba) is present

and to start appropriate treatment.

Commonly used stains for evaluation of smears are

gram stain, giemsa stain and Ziehl-Neelson stain.

Flurochromic stains like acridine orange and Calcoflour

white requires a fluorescent microscope.

Fig. 1. Method of corneal scraping

CURRENT

CONCEPTS

December 2008 Jyothi P.T. - Investigation in Microbial Keratitis 409

Gram stain is used to detect bacteria, fungal hyphae,

yeasts and cysts of acanthamoeba. It differentiates

bacteria into two groups based on the difference in the

cell wall: gram positive gram +ve appears bluish purple

and gram negative –ve appears pink.

Giemsa stain is useful to detect bacteria, fungi, cysts of

acanthamoeba, viral and chlamydial inclusion bodies.

Also detects cellular response. In viral keratitis Giemsa

stained smears will show mononuclear cells, PMNs and

eosinophilic intranuclear inclusion bodies.

Ziehl-Neelson stain detects mycobacteria as well as

nocardia.

Acridine Orange detects bacteria, fungi and

acanthamoeba

Calcoflour white detects fungi and acanthamoeba

Potassium Hydroxide (KOH) wet mount – 10 %

Highly sensitive and very reliable test for recognition

of fungal filaments (fig 2) and acanthamoeba cysts.

Thin branching filaments of nocardia can also be seen.

Scraped material is spread on a clean glass slide, one

drop of 10 % KOH is added. Coverslip placed on it and

examined under low power and high power. 10 % KOH

clears the cellular debris and make the hyphae

fragments more refractile and prominent. It can be used

alone or with ink or lactophenol cotton blue (LPCB)

Gomori Methenamine Silver stain is the best stain for

visualization of fungi. Cell wall and septa stain black

against the light green background. It is time consuming

and difficult to perform. (Fig. 4)

Lactophenol Cotton Blue mount - very useful to detect

fungi and acanthamoeba. (Fig. 3)

Identification of organisms by culture

Corneal infections usually yields very small quantities

of material for culture.Therefore direct innoculation

of scraped material onto the culture medium improves

the yield of culture.

Commonly used media and organisms isolated

Standard media

1. Blood agar plate- Standard media for the isolation

of aerobic bacteria It also supports the growth of

many fungi . Fusarium grows well in blood agar.

(Fig. 5).

2. Chocolate agar- Haemophilus,Neisseria and

Moraxella grows well in Chocolate agar

3. Sabouraud’s dextrose agar-Universal media for the

fungus.Most ocular fungi demonstrates growth

within 2-3 days, but wait for atleast 2 weeks before

considering culture as negative.

4. Thioglycollate broth - Supports the growth of a

number of aerobic and anaerobic bacteria. Contains

basic nutrients supporting the growth of aerobic

Fig. 2: KOH Mount

Fig. 3. Lactophenel cotton blue mount showing a new of

Aspergillus

Fig. 4: Gomori Methenamine silver stain

Fig. 5: Aerobic bacteria in blood agar


bacteria and sulfhydril compounds that act as

oxygen reducing agent to facilitate growth of

anaerobic bacteria.

Additional media

5. Non nutrient agar plate with E coli overlay-This

media is used for the growth of acanthamoeba.The

organisms consumes E coli and the migrating

organisms are seen as tracks.

6. Thayer martin agar plates-Chemically enriched

chocolate agar that suppress the growth of inhibitory

contaminants and allows isolation of Neisseria.

7. Brain Heart Infusion broth with Gentamicin-Liquid

media. Enhances the recovery of filamentous fungi

and yeasts

8. Lowenstein Jenson Agar plate-Supports the growth

of mycobacteria

Innoculation in plates should be done in multiple “C”

Streak pattern (Fig. 6)which facilitates differentiation

of valid growth from contaminants.Growth of the C

streak is considerd significant whereas growth outside

C streak is considerd as contaminants.

in viral transport medium and sent to the

laboratory.With herpes simplex, cytopathic effects are

seen within 24- 48 hrs, but may take as long as 7 days.

Detection of antigens and antibodies

Detection of various microbial antigens in tissue

specimens help in the rapid diagnosis of infection.Direct

immunofluorescence staining of smears with fluorescein

conjugated monoclonal antibody against HSV

glycoprotein is a rapid diagnostic test, but requires a

fluorescent microscope. Enzyme linked immunosorbent

assay (ELISA) tests identify different antigens in

specimens.Serological tests to detect IgG and IgM

antibodies are useful for the detection of viruses and

microsporidia

Limulus lysate test

It is a fairly accurate and quick test for detecting

endotoxins in corneal specimens. Endotoxin is a

lipopolysaccharide in the cellwall of gram negative

enteric organism and its detection would indicate that

one of these organisms were present in the specimen.

The horseshoe crab limulus polyphemus produces cells

coelomic amoebocytes which cause clotting when

exposed to endotoxin. The endotoxin activation of the

coagulation pathway has been adapted as a sensitive

in-vitro assay for the presence of bacterial

lipopolysaccharide. Corneal scrapings are emulsified

in a test tube with amoebocyte lysate reagent. If

endotoxin is present, a visible clot is formed.

Polymerase Chain Reaction(PCR)

PCR is an effective method of detecting very small

quantities of microbial DNA or RNA in samples. Any DNA

or RNA that matches the probe DNA sequence is amplified.

Appropriate probes must be determined for each

organism tested.The DNA or RNA sequence of the probe

must be unique to the organism.Very useful test for the

detection of viruses, acanthamoeba and microsporidia.

Test is expensive and false negatives can occur.

Confocal microscopy

Confocal microscopy is a new imaging technique which

provides an optical section of the tissues and provides

An isolate is likely to be significant if

1. Smear results are consistent with culture.

2. Same organism is grown in more than one media

3. Same organism is grown in repeated samples

In all cases, the results should be correlated with the

clinical features

Cell culture for isolation of Viruses

The isolation of virus in tissue culture provides a

definitive diagnosis.The lesion is swabbed and placed

Fig. 6. Innoculation as C Streak pattern

December 2008 Jyothi P.T. - Investigation in Microbial Keratitis 411

images from different depths. Although not widely

used, it is useful in the detection of cysts of

acanthamoeba and fungal filaments in vivo. It can also

detect parasites like microsporidia and certain bacteria.

In the diagnosis of microbial keratitis, use

tests which are sensitive, specific and

affordable and use them selectively. Careful

clinical examination and direct miscroscopy of

corneal scrapings stained by simple methods

allows a rapid presumptive aetiological

diagnosis. Where facilities are available,

culture of organism should be done in all cases

of moderate to severe microbial keratitis.

References

1. Daniel M. Albert,Frederick A Jakobiec Priciples andpractice of Ophthalmolgy. vol 2

2. Graysons disea se of cornea

3. Krachmer, Mannis, Holland, Fundamentals of corneaand external diseases

4. Jayahar M.Bharathi, M.Sreenivasan, R. Meenakshi,S.Padmavathy, Prajna M. Lalitha A study of spectrumof acanthamoeba keratitis, IJO 2007; 55: 37-42.

In a lighter vein

Of Protocols, Procedures and PracticesRRV

Let me assure you, the words in the title are not

used in a clinical sense. It is actually part of the title

of a book dealing with conduct of official meetings.

This fictious book invented by yours truly in self

defense has saved the situation (and my face) more

than once.

Our Society conducts a lot of meetings now. The

bigger of them are conducted with more formalities

and protocols. Many are the funny moments

generated in some of them. The non-Ophthalmic

MCs and speakers stumbling on ophthalmic terms

are one category. Ophthalmic MCs and speakers

doing the same with general terms are equally

hilarious.

The first ritual in any major meeting would be the

investiture of the President. Surprisingly many of

our MCs are not familiar with the term ‘invest’ or

‘investiture’. Many may know that it is something to

do with the Presidential collar. The funniest usage

was heard in the SROC meeting in a provincial town

in A.P., where the MC invited the Secretary to “collar”

the President. He definitely must have been unaware

of the nuances of the many meanings of ‘collaring’.

In another venue I heard the Secretary being invited

to “put the collar on the President”. Really it invoked

canine images! In one of our annual conferences

the MC (a senior Ophthalmologist who wouldn’t

listen to any advice) preferred a more flowery and

regal sounding “adorning the president with the

collar”. Two terms back, our local IMA Secretary

solved the problem in simple and straight-forward

way by announcing, “With your permission I am

putting ‘this thing’ on the President”. (But then he

substituted ‘this thing’ for any word/phrase that did

not occur to him in time).

Many of our MCs and speakers seem to feel that

stage is for performances and a meeting is conducted

on a dais. Rightly so; but most of them pronounce it

as ‘dias’ and as ‘diayas’ once in a while.

Another word which is most usually mispronounced

is ‘memento’, meaning things given away to

remember the occasion by. Recently in a ‘mega’ CME

conducted hereabouts, a willowy MC with ‘convent’

English and a put on accent took on the floor. First

she got the name of the chief guest wrong and later

blithely announced, “Now Dr. So and so will give a

MOMENTO to the chief guest”. The chief guest gave

me, who was supposed to do the honours, a startled

look. Later, realising the true meaning, murmured:

“Thank God, it is not MOMENTUM”.


Parasitic KeratitisDr. Ranjakumar MS MBA(HM)

Various parasitic infections are important causes of

ophthalmic diseases worldwide.Most parasitic

infections are spread by insect vectors or consuming or

getting contact with contaminated water.There are

fairly obvious reasons why parasitic diseases are found

mainly in tropics:

� The warm climate encourages the growth and

survival of the parasites

� The warm climate encourages the insect vectors

� Poor sanitation and poor water supply makes the

food/water contaminated

� People live in close contact with domestic animals

which are involved in the life cycle of some

parasites

Various organisms producing keratitis are the following:

Acanthamoeba

Microsporidia

Onchocerca

Leishmania-

Trypanosoma bruci

Echinococcus granulosus

Crab louse –Marginal Keratitis(IJO 1976-Dr.Ittyerah)

Other free living amoeba –Vahikampia/Hartmanella

Acanthamoeba keratitis

Background

These amoebae are distinct from other pathogenic

protozoa. They have a free living existence, have no

human carrier state(which is important in disease

transmission), and have no insect vector.

The pathogenic species of Acanthamoeba known to

produce keratitis are the following

1. A castellani

2. A polyphaga

3. A hatchetti

4. A culberstoni

5. A rhysodes

6. A griffina

Out of these castellani and polyphaga are commonly

associated with keratitis whereas culberstoni is rarely

encountered but highly virulent.

Life Cycle

The life cycle consists of 2 stages:

1. Trophozoite (14-40 μm in diameter)

2. Cyst (12-16 μm diameter & a double layered wall)

Dept. of Ophthalmology, Medical college, Kozhikode

Acanthamoeba genus causes 3 clinical syndromes .

Granulomatous amoebic encephalitis, Disseminated

granulomatous amoebic disease (eg- skin, sinus, and

pulmonary infection) Amoebic keratitis.

Patients who develop the first two are usually

immunocompromised whereas those who develop

keratitis are immunocompetent.

Fig. 1. Isophozotic and Cyst of Acanthamoeba

CURR EN T

CONCEPTS

December 2008 Ranjakumar - Parasitic Keratitis 413

Acanthamoeba was first established as a case of human

disease in1973

This vision threatening corneal disease was first

recognized in contact lens wearers.

There was a sharp increase in the recognition(and

perhaps incidence ) of this disease in the late 1980’s.

First case of Acanthamoeba keratitis from India was

reported in 1987 from Aravind Eye Hospital, Madurai

Epidemiology

Acanthamoeba are free living, ubiquitous pathogenic

protozoa. They are isolated from soil,water(including

natural and treated) air and dust. Most persons appear

to have been exposed to this organism during their life

time as 50-100 % of healthy people have serum

antibodies against acanthamoeba. Studies have also

demonstrated that this amoeba can be cultured from

nasopharynx of healthy individuals. Acanthamoeba

cysts are very resistent to chlorine. It converts from

trophozoites to more durable cyst form during

unfavourable conditions, making the organism highly

resistant to killing by desiccation, irradiation or

chlorination. Acanthamoeba thrives in soil, ponds,

swimming pools and contact lens solution.

Despite widespread prevalence in nature, the incidence

of keratitis is low because, it is a weak pathogen and

there is a high degree of innate host resistance.

Trophozoites are probably more important than cysts

in initiating keratitis.

The incidence of Acanthamoeba keratitis accounts

for 1-4 % of proved keratitis. Mud as a cause for corneal

trauma resulting in Acanthamoeba keratitis is

significantly more than any other material. Contact lens

wear does not emerge as an important risk factor for

the development of Acanthamoeba keratitis in our

population.

Pathophysiology

The occurrence of infection is multifactorial. .Keratits

occurs in patients with minor corneal trauma. Minor

trauma in western countries is due to content lens wear.

Amoeba are introduced via contaminated solution or

wearing lenses while swimming. All types of content

lens can predispose to this. In our country, people

belonging to poor socio economic strata are affected

(who are using unclean, contaminated water for

washing eyes). 60 % of cases in our country are due to

ocular trauma. Humans come into contact with amoeba

while swimming in lakes, pools, sea water and also on

contact with mud and tap water. This direct exposure

combined with minor trauma leads to corneal infection

Clinical features

Patients will have similar symptoms as with other forms

of keratitis, but pain will be out of proportion to the

findings.

Clinical signs are discussed in three stages

1. Early stage Epithelial defects, epithelial haze,

pseudodendrites

2. Late stage Epithelial defects, stromal

infiltrates, nummular keratitis

3. Advanced stage Ring infiltrate, satellite lesions,

stromal abscess (Fig. 2 a-d)

Other features

- Severe anterior and posterior uveitis

- Nodular or Diffuse scleritis

- Corneal stromal infiltrates (single,multiple,ring shape)

- Anterior uveitis (transient hypopyon)

- Radial keratoneuritis

- Disciform keratitis

Fig. 2. Clinical findings in acanthamoeba keratitis

(a) epithelial haze (b) pseudo dendrites (c) Ringinfiltrate (d) stromal abscess


Clinical characteristics that help to distinguish

Acanthamoeba keratitis from other keratitis include the

following:

1. Ring infiltrate

2. Elevated epithelial lesion

3. Relative lack of vascularisation even in chronic and

severe cases

Clinical Diagnosis

Acanthamoeba keratitis poses a diagnostic challenge

because of its similarity to fungal and viral keratitis.

Most often Acanthamoeba keratitis in early stage is

misdiagnosed as herpes simplex keratitis, and in late

stage as fungal keratitis. There will be a history of

trauma with soiled water, organic matter, and rarely

contact lenses. Adults engaged in outdoor work are

affected mainly. Suspect when the response to antiviral

or antibiotic drugs is poor or absent. Patient might

have had several consultations with different

Ophthalmologists before a proper diagnosis is

established.

Laboratory Diagnosis

Acanthamoeba trophozoites or cysts can be

demonstrated in corneal scrapings or a biopsy sample

via wet mount, stains, histopathologic examination or

culture

10% KOH wet mount is used routinely as an initial

procedure to identify cysts and to exclude fungi.

Sesitivity of this test is almost equal to Calcoflour white.

Motile trophozoites may be seen in a wet mount

preparation.

Stains commonly used are

Geimsa Cysts & Trophozoites stain

purple

Lactophenol cottonblue Cyst wall stains green/

Trophozoite red

Gram Cysts show as multisided

gram positive crystals

Calcoflour white Cyst wall stains green/

trophozoite red

PAS

Other diagnostic options :

Indirect fluorescent antibody staining

Confocal microscopy: This provides in vivo views

of the cornea and delineates both trophozoites and

cysts. The double walled cysts are particularly prominent

and radial keratoneuritis can be appreciated. This can

also be used to monitor the patient on treatment.

Equipment is costly and is available only in specialized

centres. If corneal specimens are unremarkable consider

culturing contact lens or cleansing solution for amoeba

Culture Acanthomeba could be isolated by inoculating

the specimen on non nutrient agar with E.coli overlay.

The plate should be incubated for more than a week.

Acanthamoeba feed off the bacteria, leaving linear

tracks(migration tracks/snail tracks) in the plates.

Tissue specimens.corneal smears, contact lenses and

swabs may be kept in Page’s saline (phosphate buffered

saline) and sent to lab, if materials for culturing are

not available (fig 7)

An alternative to non nutrient agar has also been

described.Corneal scrapings may be inoculated in

tissue culture flask containing suspension of E.coli in

¼ Ringer solution. The flask is incubated at 37ºC and

examined daily for trophozoites using an inverted

microscope.

Superinfecting bacteria can complicate the diagnosis and

isolation of bacterial pathogen does not exclude

Acanthamoeba as the cause for keratitis

Treatment

There is no consensus on treatment. Various regimens

are described. Treatment is required for 6-12 months.

Prolonged medication results in corneal vascularisation

and toxic keratitis.

Fig. 7. Acanthomeba in culture on non nutrient agar withE. Coli overlay


Drugs used are:

1. Aromatic diamidines - Propamidine isethionate

0.1 %

Dibromopropamidine

ointment 0.15 %

(Brolene eye ointment,

not avialble in India)

2. Aminoglycosides - Neomycin

3. Imidazole & Triazole antifungals

4. Polymyxins

5. Cationic antiseptics - Polyhexamethylene

biguanide (PHMB)

0.02 %

Chlorhexidine 0.02 %

Primary agents used are biguanides as they are both

trophocidal and cysticidal and also less toxic to cornea

than aminoglycosides and antifungals.

Drug Trophicidal Cycticidal

Chlorhexidine + +

PHMB 0.025% + +

Propamidine 0.1% + +

Neomycin + -

Clotrimazole + -

Initial approach can be-

1. Cationic antiseptics in combination with neomycin

and propamidine.

2. A combination of topical biguanide and diamidine

therapy.

(Pentamidine is not available in India)

Treatment is divided into three phases

1. Loading dose - On days 1 to 3.The patient is given

chlorhexidine or PHMB and propamidine with or

without neomycin. Each drug is given hourly.

2. Intensive treatment - On days 4 to 7.Above

regimen is repeated, 2hrly during day and 4hrly at

night.

3. Maintenance phase. From day 8 onwards for

atleast 4 months-chlorhexidine or PHMB with or

without propamidine 6hrly.

A regimen which can be advocated here is as follows:

PHMB 0.02% hrly for 1week, 2 hrly for 2 weeks, 4 hrly

upto 8 weeks.

If no toxicity,continue 4-6 hrly till it heals,which may

require nearly 1 year.

(Prolonged use of PHMB promotes corneal vascularistion

which is reversible when drug is tapered/withdrawn)

Combine Adjuvant therapy

Topical steroids is controversial as it will foster

conversion of cyst to trophozoite

Systemic therapy

Itraconazole/ketaconazole 600mg/day orally

Pentamidine IV in recalcitrant cases 4 mg/kg/d i/v. After

first 3 doses reduce to 3mg/kg/d to minimise toxicity

Surgical treatment

Epithelial debridement: Effective in early phase

in combination with antimicrobials.

This will improve penetration of the drug and facilitates

removal of pathogen

Penetrating keratoplsty: Timing of sugery is

critical. It is unwise to perform keratoplasty before

infection is controlled or organism is fully eradicated,

otherwise graft recurrence will occur. But if impending

perforation is seen, keratoplasty may be done,with risk.

Optical graft may be done after complete resolution of

infection.

In general,treatment of Acanthamoeba keratitis has

been disappointing, partly because the infection is

frequently well advanced before diagnosis and partly

because the available treatment is suboptimal.

Successful treatment requires early diagnosis and

aggressive medical and surgical management.

Conclusion

Acanthomeba keratitis is a challenging disease to

Ophthalmologists. Prevention is the only method till

we get a specific drug. Contaminated water is the source

of infection in our region hence prevention is a difficult

task.


Microsporidiosis

Microsporidians are obligate intracellular parasites and

are omnipresent (fig 8)

Microsporidial keratitis was first described in 1973

Three species are known to cause keratitis

Encephalitozoon hellum Imuno compromised cases

Nosema corneum Immunocompetent cases

Nosema ocularum Immunocompetent

10 mg/ml suspension of fumagillin can be applied

hourly for 24 hrs and then tapered. Complete

resolution of symptoms has been reported in a period

of 3 days.

Onchocerciasis (River blindness)

The causative organism is a filarial nematode

Onchocerca volvulus which is transmitted by the

Simulium black fly. There is transplacental

transmission also

Eye disease is related with inflammatory response

generated by nematodes, which can be found in the

conjunctival epithelium, corneal stroma, iris, ciliary

body, sclera, extra ocular muscles and optic nerve sheath

Manifestations

Inter palpebral marginal keratitis, Sub epithelial

opacities, Stromal oedema due intrastromal worm are

some of its clinical manifestations. Cornea may contain

large numbers of living microfilaria. Worms are

visualized in the slit lamp on retro illumination. Calcific

band keratopathy and both anterior and posterior

uveitis may be associated with river blindness.

Microfilaria may be observed in the anterior chamber

especially in the inferior angle on gonioscopy, or seen as

moving shadows against red background with

ophthalmoscope.

Diagnosis Based upon the identification of the worm

from skin snips

Diagnosis is also confirmed by Mazzoti test: 30 minutes

after oral administration of diethyl carbamazepine

patient develops pruritis, erythema, flu like symptoms.

After the drug administration microfilaria can be

recovered from urine and blood.

Treatment

The mainstay of treatment is oral Ivermectin as single

dose (150 μgm/kg) and repeated every 6 months to

1 year.

Because of the more complex scenario as well as wide

variety of pathological manifestations,each ocular

disease has to be addressed individually, including

epidemiology, pathogenesis, diagnosis and treatment.

Fig. 8. Microsporidial spore

Microsporidial infection produces -

stromal keratitis and iritis in immunocompetent

individuals, conjunctivitis and epithelial keratitis in

immunocopromised patients.

Epithelial lesions are characterized by multiple

coarse white grey opacities and decreased corneal

luster. In addition there will be a fusiform swelling

in the inferior fornix from which microsporidia are

recovered

Microsporidians are difficult to culture, hence diagnosis

is made by direct observation of organism.On gram stain

microsporidians appear as gram positive, ovoid

intracytoplasmic iclusions

Confocal microscope can reveal the organisms,but

these organisms approach the resolution limits of this

instrument

Electron microscopy is considered the gold standard

for diagnosis

Treatment

Itraconazole Orally

Propamidine Topically

Fumagillin Topically


“Less-Than-Perfect Outcomes”

After An Uneventful Cataract SurgeryDr. Meena Chakrabarti MS, Dr. Valsa Stephen MS, Dr. Sonia Rani John DNB, Dr. Arup Chakrabarti MS

Astute and self absorbed patients will usually find a lot

of “little things” to feel disappointed about. Most often

lending a sympathetic ear and offering scientific reasoning

of their complaints reassures this group of trouble makers.

In the present cataract surgery scenario the patient

expectations are very high, and doubly so, for those patients

who opt to have “premium” IOLs implanted in their eyes.

When a patient complains of decreased visual function

after an uneventful cataract surgery you should have a

definite game plan. Typically we have to look for 3

things- ocular surface disease, early posterior capsular

opacification, and cystoid macular oedema. All these

causes are magnified and multiplied in the unfortunate

multifocal IOL patient.

My vision is coming and going .…..group

Posterior lid margin disease and Meibomian Gland

Dysfunction (MGD) are recognized as significant causes

of decreased quality of vision in a cataract patient. The

meibomian gland can become inflamed, the oil

abnormal or unstable, both of which may cause the

tear film to become unstable with rapid tear break-up-

time. If your cataract patient complaints that his vision

is “coming and going”, it is consistent with posterior

lid margin disease. Other tell tale signs include

telengiectasia around the gland orifice, gland dropouts,

or ‘foam’ in the tears.

Other OSDs that may cause subnormal vision includes

1. Aqueous deficiency dry eye.

2. Epithelial basement membrane debasement

A very common scenario in our day to day practice is a

disgruntled and grumpy post operative patient. This

article will focus on how to handle such a situation,

what to look for and to effectively streamline our

management options.

Majority of the cataract surgeons perform uneventful

surgeries (no intraoperative surprises) most of the time.

On few occasions we anticipate a particular intra

operative difficulty, and with good prior planning we

are able to efficiently manage the complication and give

an excellent outcome. In this situation the patient is

already counseled on the less-than-perfect outcome and

usually he willingly accepts the final visual result.

Imagine the scenario where you have performed an

uneventful cataract surgery in an uncomplicated eye

and contrary to your patient being another of your

success stories, you have a pessimistic disgruntled

individual in your OPD infecting other waiting clients

with his pessimism.

Assuming an uncomplicated procedure, some outcomes

are going to be due to patient –specific factors. For

example patients with diabetes have higher risks of

postoperative macular oedema as are patients with

preexisting uveitis and retinitis pigmentosa.

Age is also a major determinant. Wound healing is

faster in younger patients and hence there is a higher

incidence of wound dehiscence, or leaks in the

elderly.

Chakrabarti Eye Care Centre, Kochulloor, Trivandrum - 695 011


C O M M U N I T Y

OPHTHALMOLOGY


3. Salzmann’s disease

4. Subtle corneal oedema

Patients with aqueous deficiency, complain that their

vision gets worse as the day progresses. Salzmann’s

disease typically affects women in 95 % of cases. In the

classic form subepithelial fibrosis is easily distinguished.

However the more subtle forms of this entity may be

entirely missed unless the cornea is examined by

oblique illumination.

“Fine till I had my cataract surgery” group

“Fine until I had my surgery” group of patients

attribute all their preexisting little complaints to the

cataract surgery. A common complaint is seeing floaters-

possibly the patient just did not notice their floaters

until they had the surgery. The cataract surgery is not

the cause but may be it brought this complaint to the

forefront.

The Keratitis Medicamentosa patient

Many of our cataract patients are toxically exposed

to preservatives such as BAK present in the steroid

and nonsteroidal anti-inflammatory drops that we

prescribe. Keratitis Medicamentosa is seen in a fairly

large subset of elderly postoperative patients.

Remember also to check the patients IOP regularly-

you may never know that you have a ‘steroid –

responder’ in your hands.

The Borderline OSD patient

Beware of the cataract patient who firmly believes that

the cause of his foreign body sensation is “the cataract”

and is hell bent on a surgical procedure. A good dose

of strong and effectively loaded worded counseling will

have the desired effect of dispelling the patient’s assumptions

and gives him a realistic expectation of the postoperative

outcome. In majority of this subset of patients, their

“borderline OSD” goes unrecognized before surgery. In

the surgeons eagerness ‘to cut’ he erroneously assumes

that the patients vague complaints are due to his

cataract! and the procedure tips the scale towards a

frank OSD and a disgruntled symptomatic patient.

Undetected preexisting astigmatism

Irregular astigmatism may be missed preoperatively or

we might be faced with a patient who has a subtle

Keratoconus.

The unhappy Multifocal patient

A subtle change or wrinkling in the posterior capsule

goes unnoticed by majority of patients. But for the

multifocal patient even if he is reading 6/5, subtle

changes yield visual complaints. Early Yag capsulotomy

can be advised in these patients if their visual

complaints persist.

Subtle Macular pathologies

Any one from any of the major institutes around the

world will tell you that even in patients who look

normal, OCT will pick up subtle macular pathologies

such as ripe cyst, macular drusen, partial thickness

macular hole or a vitreo macular traction. The

presentation can be very subtle and the clinician may

miss it during biomoicroscopy.

Know – your - Patient well

Retinal photo toxicity and CME are 2 other diagnosis

to ‘look- at’ in patients who have subnormal

postoperative vision.

Preoperative topography, OCT and angiography should

be used judiciously before surgery to detect subtle

changes that causes subnormal vision in a predisposed

patient. It goes a long way to ‘know your patient’ well

before subjecting him to the knife. An unhappy patient

spoils the day for you and your team and it really takes a

lot of effort to pacify him and even more hard work to make

him come back to you for his other eye cataract surgery.

A thorough preoperative evaluation, meticulous

examination of the ocular surface, reliable refraction

and Keratometry, ocular imaging to rule out subtle

macular pathogenesis all go a long way in ensuring

that your patient’s postoperative recovery is free of

surprises. The role that preoperative counseling plays

needs no emphasis especially in patients who opt for

premium multifocal IOLs.

December 2008 M. Chakrabarti et al. - Less than perfect outcomes after cataract surgery 419

Ocular Contusion Injury Due to Pelting with

Hard Boiled EggsDr. Meena Chakrabarti MS, Dr. Valsa Stephen MS, Dr. Sonia Rani John DNB, Dr. Arup Chakrabarti MS

Blunt injuries account for 51 % of all ocular injuries 1

with the majority of the retinal lesions being unilateral.

Reports in literature have included injury with bungee

cords, water balloons, golf balls, paint balls 2, 3,4 etc.

In this case report, we present the clinical features

and management of a rather severe blunt injury in a

young man following a surprisingly trivial

trauma………….a thrown hard boiled egg that hit

his eye.

Mr. X; a 22 year old computer operator was cooking

his dinner when a difference of opinion occurred

between himself and his friend. He was pelted

with several unshelled hard boiled eggs one of which

struck him in his right eye. Although he had pain

and the eye became red, he sought medical aid only

after 2 days.

Ocular examination revealed a visual acuity of 6/60 in

the right eye, a soft eye with unrecordable intraocular

pressure, uveitis with 1 mm hypopyon, and fundus

showing an increased physiological cupping, traumatic

retinal whitening and evidence of retinal contusion at

the macula ( Fig 1). Optical coherence tomography

showed evidence of intra retinal oedema with increased

retinal thickening and a subfoveal serous retinal

detachment Fig(2). He was started on topical and

systemic steroids, cycloplegics and topical as well as

systemic nonsteroidal anti inflammatory agents. When

the patient was reviewed after one week he had

symptomatic improvement, his visual acuity was 6/36

Chakrabarti Eye Care Centre, Kochulloor, Trivandrum 695 011


Fig 1 a showing traumatic

retinal whitening inthe right

Fig 1 b showing normal retinain the left

Fig 2 Optical coherence tomography showing subfovealserious detachment in the right eye

improving with pin hole to 6 /24, N8;

the anterior

segment reaction had subsided well and his tension

applanation reading was 16 in the injured eye. He was

kept under follow up while the medication 5 were

tapered. Within a period of 2 weeks he showed

remarkable improvement with a visual acuity of 6/9

N6, no evidence of anterior chamber reaction and a

fairly normal appearance of the macula. (Fig. 3). Repeat

optical coherence tomographic scan showed good

resolution of subfoveal serous retinal detachment in

the macula

C A S E

R E P O R T


angiography shows blocked choroidal fluroscence in

the early phases of the angiogram followed by intense

retinal pigment epithelial staining.

Histopathological studies 5, 6, 7 have shown that in severe

forms of contusion, the retinal opacification

corresponded to the areas of fragmented photoreceptor

outer segments. There was associated intracellular

oedema of the retina glia, loss of apical processes of

the retinal pigment epithelium, disruption of RPE

plasma membrane and formation of microcystic spaces.

No specific treatment has been found beneficial in either

retinal concussion or contusion.

Conclusion

This case is presented as a novel cause of ocular

contusion injury due to pelting with a hard boiled egg.

Since the patient had only a retinal contusion,

spontaneous recovery with good visual results and no

permanent sequlae was observed.

References

1. Ligget PE, Pince KJ, Barlow W et al Ocular trauma inan urban population: review of 1132 casesOphthalmology 97:581-584, 1990

2. Bullock J D, Ballal DR et al. Ocular and Orbital traumafrom water balloon sling shots: a clinical,epidemiological and experimental study.Ophthalmology 104:878- 887, 1997

3. Cooney MJ, Pieramici DJ. Eye injuries caused by Bungeecords. Ophthalmology 104 : 1644- 1647, 1997

4. Fireman MS, Fischer DH et al. Changing trends in paintball sport –related ocular injury. Arch Ophthalmol 118;60- 65, 2000

5. Lien AT, Keunen JE et al. Reversible cone photoreceptorinjury in commotio retinae of the macula Retina 15:58- 61, 1995

6. Mansour AM, Green WR et al. Histopathology of

commotio retinae Retina 12:24- 48, 1992

7. Pulido JS, Blaur NP et al. The blood retinal barrier in

Berlin’s oedema. Retina J 233-236, 1987.

Fig 3 showing resolution a macular oedema after 2 weeks

Discussion

Berlin in 1873 invoked the Latin term for retinal

contusion ‘commotio retinae’ to describe a transient

whitening of the retina resulting from blunt trauma.

It can occur peripherally or within the posterior

pole region in which case it is refered to as Berlin’s

oedema.

Commotio retinae consist of two variants: retinal

concussion or the more severe retinal contusion.

Retinal concussion may be regarded as one end of the

spectrum of traumatic opacification. The initial vision

following trauma is fairly good, the grey-white changes

less dramatic and haemorrhage less frequent. The

clinical changes are reversible, with no visible late

pigment scarring and good final visual acuity. Fluroscein

angiography may show blockage of the choroidal

fluorescence by the retinal opacification. There is no

leakage of dye into or under the retina. The retinal

whitening clears spontaneously in a few days.

Retinal contusion represents the other end of the

spectrum of traumatic retinal opacification. The visual

loss is more profound, the retinal whitening more

intense and haemorrhage common. These changes are

often irreversible leading on to permanent visual loss,

macular stippling, macular hole formation or an

epimacular membrane formation. Fluorescein

December 2008 M. Chakrabarti et al. - Ocular Contusion Injury 421

Lacrimal Canaliculitis, A Case ReportDr. Bindu N. Das MS, Dr. Sisira MS

Introduction

Canaliculitis is a chronic unilateral infection of the

lacrimal canaliculus which is often overlooked and

treated unsatisfactorily. Bacteria, fungi and viruses may

all produce such infection , the most common agents

reported being actinomyces. Here we report a case of

culture positive bilateral actinomyces canaliculitis

involving both upper and lower puncti.

Case Report

A 40 year old male patient presented to us with

complaints of watering and purulent discharge from

left eye of 1 year duration, pain and swelling of the left

eyelids for 2 months. On examination his vision was

6/6 in right eye and 6/12 in left eye. Examination of

left eye showed a tender fusiform swelling in the medial

one third of left upper and lower eyelids. The

neighbouring part of the conjunctiva was inflammed.

(Fig.1) There was no tenderness and swelling in the

lacrimal sac area. The upper and lower puncti were

found to be pouting with expression of tenacious pus

on pressure over the swelling. The right eye also showed

pouting of lower puncta though it did not show

swelling. Patient was asymptomatic in the right eye.

Rest of the anterior and posterior segment was normal.

He was a known diabetic on irregular treatment.

The punctum was split under topical anaesthesia using

a fine scissors taking aseptic precautions and a thick,

tenacious purulent material was expressed from the

canaliculus. (Fig.2) The casts were removed by

performing a 3- snip procedure (Fig.3) followed by

irrigation with penicillin solution (100, 000 units). The

patient was also treated with fortified penicillin eye

drops and a course of oral penicillin. The casts collected

were sent for microbiological investigations. Repeated

irrigation with crystalline penicillin drops was done in

the right eye. A portion of collected material was

inoculated on blood agar and brain heart infusion broth.

On Gram staining the organisms appeared as gram-

Dept of Ophthalmology, Kozhikode Medical College, Kozhikode Fig. 3. The casts removed after 3-snip procedure

Fig. 2a-b showing thick tenacious purulent material expressedfrom canaliculus

Fig. 1. showing conjunctivalinflammation

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positive beaded, coccoid, thin branching filaments.

(Fig.4) The patient recovered rapidly and was left with

a slit punctum and adjoining canaliculus. The remaining

portion of the lower canaliculus was intact and was

patent. Post-operatively, the swelling, conjunctivitis and

discharge disappeared (Fig.5).

Discussion

Actinomyces israelii species is a gram-positive, cast-

forming, non–acid-fast, non–spore-forming anaerobic

bacillus. Its filamentous growth and mycelia like

colonies have a striking resemblance to fungi. They are

soil organisms, often found in decaying organic matter

(eg, wet hay, straw). It is primarily a commensal

microbe found in normal oral cavities, in tonsillar

crypts, in dental plaques, and in caries teeth and enters

the lacrimal system through the nasal passage or

indirectly by means of saliva into the conjunctiva. The

anaerobic environment also helps in the growth of the

Actinomyces in the canaliculus.

Other ocular manifestations include keratitis,

conjunctivitis, blepharitis, dacryocystitis, postsurgical

endophthalmitis, and infected porous orbital implant.

Cervico-facial actinomycosis has also been reported.

Canaliculitis usually presents as chronic watering,

redness and discharge from eye. A pouted punctum is

clinically diagnostic, although it occurs in less than

50 % of all patients who are affected. Typically, the

discharge is particulate and contains concretions.The

plica may be swollen and congested, and canalicular

swelling and overlying lid erythema are often

present.The lower lid is more commonly affected, and

the lacrimal sac and the duct are usually not

involved.The disease is most commonly unilateral.

Among the reported cases almost all were unilateral,

involving the lower lid. Bilateral and upperlid

involvement as in this case is a rare presentation.

Concretions on the lacrimal canaliculus can also be due

to Candida albicans , Aspergillus niger , Fusobacterium

species, and Nocardia asteroids.

Lab Studies

Canalicular discharge and canaliculiths may be sent for

the following studies:

� Gram stain/Giemsa stain

� Culture and sensitivity (ie, blood agar, Sabouraud,

anaerobic media)

� Special stains (ie, calcofluor white)

Treatment

Actinomycetes are usually susceptible to penicillins and

cephalosporins.

Surgical Care

Failure of resolution of canaliculitis by topical treatment

necessitates surgical exploration of the canalicular

system and removal of any casts. Extensive surgery is

not always required. A 2-snip punctoplasty, cast

removal, curettage, and probing is usually done.

Subsequent lacrimal irrigation with 1 MU of penicillin

in 10 mL of sterile water may be helpful.

References

1. Jordan DR. Dacryoadenitis, Dacryocystitis, and

Canaliculitis, chapter 57. In: Cornea- Cornea andExternal Disease: Clinical Diagnosis and Management.Krachmer JH, Mannis MJ, Holland EJ, Eds. (St. Louis,Mosby). 1997;687-693.

2. Richards WW. Actinomycotic lacrimal canaliculitis.American J Ophthalmol 1975;75:155-157.

3. Pine L, Hardin H, Turner L, Roberts SS. Actinomycoticlacrimal canaliculitis - A report of two cases with areview of the characteristics which identify the causalorganism. American J Ophthalmol 1960;49:1278-1298.

4. Sridhar MS, Gopinathan U, Garg P, Sharma S, Rao GN.Ocular Nocardia infections with special emphasis onthe cornea. Surv Ophthalmol 2001;45:361-378.

5. Sharma S. Ocular Microbiology. 1st ed. (Aravind EyeHospitals Publication, Madurai) 1988:79-84.

Fig. 4. showing positivebeaded, coccoid, thinbranching filamentson gram staining

Fig. 5. P o s t - o p e r a t i v eappearance of the eye


Rips After Pricks – A Case SeriesDr. Mahesh G. MS DO DNB FRCS Ed, Dr. A. Giridhar MS, Dr. Siddharth Pawar DNB,

Dr. Ramkumar DO, Dr. Alpesh Rajput DO

Case 1: 78 year old female presented with complaints

of defective vision in right eye (OD) of 3 years duration

and recent onset of defective vision in left eye (OS)

since 3 weeks. Her best corrected visual acuity (BCVA)

in OD was 1/60 and in OS was 6/18 N6. Indirect

ophthalmoscopy and biomicroscopic examination of

right macula showed a submacular scar. Left macula

showed hemorrhagic pigment epithelial detachment

(PED) suggestive of occult choroidal neovascular

membrane (CNVM) (Figure 1a). Fundus fluorescein

angiogram (FFA) and Indocyanine green angiogram

(ICG) were done and ICG showed a plaque measuring

6.14 mm in OS (Figure 1b). During the next 2 months

visual acuity in OS dropped to 6/60 N 12. It was at this

time we advised photodynamic therapy (PDT) with

Visudyne due to sudden drop of vision in the only useful

eye. She underwent PDT followed by intravitreal

triamcinolone acetonide (IVTA) in OS. Following PDT

and IVTA, visual acuity in OS was stabilized to 6/36 N

12. Repeated fluorescein angiography confirmed the

diagnosis of RPE rip (Figure 1c and 1d).

Case 2: 72 year old gentleman came with complaints

of defective vision OD of 10 days duration and in OS of

8 years duration. His BCVA in OD was 6/36, N 36 and

in OS was 3/60. Indirect ophthalmoscopy and

biomicroscopic examination of right macula showed

haemorrhagic PED (Figure 2 a) and left eye macula

showed scarred CNVM. Digital fluorescein angiogram

(DFA) and optical coherence tomography (OCT)

confirmed the diagnosis of occult CNVM in right eye

(Figure 2b). He was advised 3 injections of intravitreal

Giridhar Eye Institute, Ponneth Temple Road. Kadavanthra. Cochin.682020


Fig. 1. (a & b) Left macula showing hemorrhagic pigmentepithelial detachment (PED) with CNVM (c & d)showing RPE rip

Bevacizumab. First injection was given on 2.6.2008.

On follow up examination on 2.7.2008, patient came

with vision of CF at 3 meter. Clinical examination, FFA

and OCT confirmed the diagnosis of RPE rip (Figure

2c and d).

Fig. 2. (a & b) showing haemorrhagic PED with occult CNVM

in right macula (c & d) showing RPE rip

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Case 3: 69 year old female was referred here for retinal

evaluation. On presentation she complained of defective

vision left eye of 2 years duration and right eye of 15

days duration. Her BCVA was 6/24 N 18 in the right

eye and 3/60 N36 in left eye. Detailed fundus

examination by slit lamp biomicroscopy and indirect

ophthalmoscopy revealed fibrovascular PED in the right

eye (Figure 3a) and disciform scar in the left eye. DFA

and OCT confirmed occult CNVM (Figure 3b). Patient

was advised intravitreal injection of anti VEGF

Ranibizumab. On one month after the first injection

her BCVA was 6/36. On completion of third dose her

visual acuity was noted to be deteriorated to 6/60.

below the detachment is usually not visible due to the

lack of optical penetration. Also there is enhanced

reflectivity and optical penetration of the choroid in

the region with the lack of retinal pigment epithelium.

Initial good vision may deteriorate later after RPE rips.

Presence of sub RPE blood is a good indicator of rip. In

cases with RPE rip there is a substantial risk of AMD

related visual loss in the fellow eye. The risk is 37 % -

1yr, 59 % - 2 yr, 80 % - 3 yr due to PED, CNV, and RPE

tear. This is evident in our cases where there are large

scars at the macula in the fellow eyes of all the three

cases.

Anti-VEGF agents act by reducing angiogenesis and

arresting the CNVM.

The same pathology of fibrovascular tissue contraction

may be at work in RPE rips following anti-VEGF therapy.

The risk of an RPE rip should be considered with

treatment with anti-VEGF agents in cases with

fibrovascular PED.

Treatment of CNVM is aimed at regressing the vascular

elements of CNVM. Once there is conversion of vascular

network into fibrous tissue it contracts due to the

inherent property. If this is attached to the PED RPE

tear can result. Same mechanism acts in PDT and anti

VEGF treatment. This is to be kept in mind when there

is a large fibrovascular PED.

Conclusion

RPE rip can result from treatment for CNVM especially

in cases of occult CNVM with very large fibrovascular

PED in which other eye also shows severe involvement.

References

1 Schoeppner et al. Am J Ophth. 1989; 108:683-685.

2. Subramanyam A, Phatak S, Chudgar D. Large retinalpigment epithelium rip following serial intravitrealinjection of Avastin in a large fibrovascular pigment

epithelial detachment. Indian J Ophthalmol 2007;55:483-6.

Deterioration of visual acuity led to suspicion of RPE

rip (Figure 3c), which was diagnosed later with the

help of fluorescein angiography.

Discussion

RPE rip was first reported in 1981 by Hoskin et al (BJO

1981; 65:147) as a complication of serous PED in

ARMD patient. It is usually seen to occur at or along

the border of the serous RPE detachment on the side

opposite to the location of the choroidal neovascular

membrane (CNVM). FFA shows marked early

hyperfluorescence at denuded area without leak and

staining of the choroid and sclera later. Folded

epithelium mound blocks fluorescence which may leak

later. The lack of leak differentiates rip from classic CNV.

OCT image exhibits a well-defined elevation of the

neurosensory retina and double layered highly reflective

pigment epithelium. The choroidal neovascularization

Fig. 3. (a) Fibrovascular PED in the right eye (b) DFAshowing occult CNVM (c) showing RPE rip in the righteye on follow up


Combined Cilioretinal Artery Occlusion and

Central Retinal Vein Occlusion -

A Case ReportDr. Valsa T. Stephen MS, Dr. Sonia Rani John DNB, Dr. Meena Chakrabarti MS, Dr. Arup Chakrabarti MS

Cilioretinal artery occlusion present in 5 % of patients

with central retinal vein occlusion giving an erroneous

picture of a poor visual prognosis. However in majority

of patients the occlusion is transient as demonstrated

in the case history given below.

A 37 year old male with no systemic illness presented

with sudden loss of vision in his left eye. On

examination, best corrected visual acuity was 6/6, N6

in the right eye and CF ½ m in the left. Applanation

tonometry was 16mm Hg in both eyes. Anterior

segment was within normal limits. Dilated fundus

evaluation showed dilated and tortous veins in the left

with few superficial haemorrhages and an area of

whitening in the superior macular region below the

superotemporal vessel.The right eye was normal

(Fig 1a & b).

The patient was started on Tab. Trental 400 mg twice

daily and dorzox eye drops 3 times. A digital fluorescein

fundus angiogram was done which revealed a non

ischemic central retinal vein occlusion in the left eye

with cilioretinal artery occlusion (Fig 2a & b). The right

Fig. 1. (a & b): Normal fundus in the right (a) and centralretinal vein occlusion and cilioretinal artery occlusion

in the left eye

Fig. 2. (a & b) FFA in the left showing non-ischaemic CRVOwith cilioretinal artery occlusion

Fig 3 Normal FFA in the right eye

eye was within normal limits(Fig 3). Blood

investigations including ESR, serum lipid profile, ANA

and LE cell were performed. He was advised a

cardiology consultation following which inj. heparin

was given. On review after 2 days, his vision and fundus

were status quo. All investigations including cardiology

work up were within normal limits. On review after

one month, his vision had recovered to 6/6 B in the

left with near complete resolution of the central retinalChakrabarti Eye Care Centre, Kochulloor, Trivandrum - 695 011,


C A S E

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vein occlusion and complete resolution of the

cilioretinal artery occlusion (Fig. 4).

Discussion

Cilioretinal artery usually enters the retina from the

temporal aspect of the optic disc separate from the

central retinal artery and can be seen clinically in about

20 % of eyes. Fluorescein angiographically, they are

visible in approximately 32 % of eyes 1. In a normal

flurescein angiographic sequence, they usually fill with

the choroidal circulation, about 1-2 seconds before filling

of the retinal artery.

Ophthalmoscopically, a cilioretinal artery obstruction

appears as an area of superficial retinal whitening along

the course of the vessel. The following clinical variants

have been described 2. 1) isolated ciliio retinal artery

obstruction 2) cilioretinal artery obstruction associated

with central retinal artery obstruction 3) cilioretinal artery

obstruction associated with anterior ischemic optic

neropathy. Cilioretinal artery obstruction along with

central retinal vein obstruction makes up just greater

than 40 % of cases of cilioretinal atery obstruction 2.

The venous obstruction are generally non ischemic and

therefore do not usually lead to rubeosis iridis and

neovascular glaucoma 2, 3, 4. However, it is possible for

a cilioretinal artery obstruction to be difficult to detect

in the presence of an ischemic central retinal vein

obstruction causing the incidence of rubeosis iridis to

be falsely low in this subgroup with cilioretinal artery

obstruction. Approximately 70 % of these eyes achieve

20/40 or better vision 2 with the venous obstructive

component accounting for the greatest degree of visual

loss. Fong and colleagues 5 have noted that 5 % of

patients with central retinal vein obstruction also have

cilioretinal artery occlusion. The reasons for this

association are unclear. Reduced hydrostatic pressure

in the cilioretinal artery, as compared to the central

retinal artery, may predispose the cilioretinal artery to

stasis and thrombosis in the setting of increased hydrostatic

pressure within the retinal venous system 3, 4. In addition,

swelling of the optic disc may compromise the cross

sectional area of the cilioretinal artery and lead to

reduced flow. According to Poiseulle’s law, the flow

within a blood vessel is proportional to the fourth power

of the radius of the vessel. Thus flow within a vessel

with twice the radius of a second vessel will be 16 times

that with the similar vessel.

The systemic work up for causes of cilioretinal artery

obstruction is similar to that for central retinal artery.

An extensive work up for the embolic sources is probably

not indicated however for cases of associated with CRVO.

Ocular treatment is not usually given. Studies have

shown that eyes with combined CRVO and CRAO with

recent visual loss respond well to superselective

ophthalmic artery fibrinolytic therapy with urokinase 6.

Another study showed no alternation on course of the

disease with intravitreal tissue plasminogen activator 7.

In this case, the obstruction resolved completely in one

months time with return of vision to 6/6.

References

1. Justice, J Jr, and Lehmann, RP: Cilioretinal arteries: Astudy based on review of stereo fundus photographsand fluorescein angiographic findings, Arch Ophthalmol94:1355-1358, 1976.

2. Brown, GC, Moffat, K, Cruess, AF, Magargal, LE, andGoldberg, RE: Cilio retinal artery obstruction, Retina3: 181-187, 1983.

3. Mc Leod, D, and Rig , CP : Cilio- retinal infarction afterretinal vein occlusion, Br. J. Ophthalmol 60:419-427,1976.

4. Schatz, H, Fong, ACO, McDonald, HR, Johnson, RN, Jeffe,L, Wilkinson, CP, deLaey, JJ, Yannuzzi, LA, Wendel, RT,Joondeph, VC, Angioletti, LV, and Meredith, TA: Cilioretinalartery occlusion in young adults with central retinal

vein occlusion, Ophthalmology 98: 594 - 601, 1991.

5. Fong, ACO, Schatz, H, McDonald, HR, Burton, TC,

Meberly, AL, Joffe, L, Zegarra, H, Nadel, AJ, andJohnson, RN: Central retinal vein occlusion in youngadults, Retina 12:3-11, 1992.

6. M Pagues, J N Vallee et al. Super selective ophthalmic

artery fibrinolytic therapy for treatment of CRVO. Br. J.Ophthalmol 2000 84(12) 1387-91

7. A Glacet Bernard, D Kahn et al - Treatment of recentonset CRVO with intravitreal tissue plasminogenactivator. A pilot study Br. J. Ophthalmol 2000 June84(6) : 609-13

Fig. 4. showing complete resolution of cilioretinal arteryocclusion with partial resolution of CRVO


Leber’s Multiple Miliary AneurysmDr. Valsa T. Stephen MS, Dr. Sonia Rani John DNB, Dr. Meena Chakrabarti MS, Dr. Arup Chakrabarti MS

In 1912 and 1915, Theodor Leber described a disease

with similar vascular findings to Coats but which lacked

the massive subretinal exudates described by Coat. This

syndrome was later named Leber’s multiple miliary

aneurysm disease. In 1915, Leber concluded that what

he had described was merely an earlier stage of Coats

disease1. This conclusion was later reinforced by Reese2 who described an eye with Leber’s miliary aneurysm

that progressed into a clinical case of Coats disease

during long term follow up. Most authors today clarify

Leber’s disease as an early or non progressive form of

Coats 1.3. This photoessay describes the classical features

Chakrabarti Eye Care Centre, Kochulloor, Trivandrum - 695 011, E-mail: [email protected]

Fig. 1. (a) Right fundus showing multiple hard exudates in the macular region with the extensive exudation extending intothe infero temporal retina and numerous vascular anomalies. (b) Normal left fundus

Fig 3a & b Fundus fluorescein angiography showing multiple miliary aneurysms,intra retinal shunts and nonperfusion areas

in the macula and inferotemporal retina in the right eye

P H O T O

E S S A Y


Fig 4a&b showing stable retina post sector photocoagulation in the right on review after 1 month

Fig 5a&b Right and left fundus on review after 3 months

Fig 6a&b showing new vessel anomalies in the right eye on FFA after 3 months.

of Leber’s multiple miliary aneurysm in a 34 year old

school teacher.

Case History:

A 34 year old female presented in our OPD with

complaints of blurring of vision in the right eye of 3

days duration. She had no history of any systemic

illness. On examination, her best corrected visual acuity

was 6/18, N12

in the right eye and 6/6, N6 in the left

eye. Her external eyes were within normal limits. On

dilated examination, the right fundus showed multiple

hard exudates in the macular region with the extensive

exudation extending into the infero temporal retina and

numerous vascular anomalies (Fig. 1a) suggestive of

Leber’s multiple miliary aneurysm. The left retina was

normal (Fig. 1b). A fundus fluorescein angiography

showed multiple miliary aneurysms,intra retinal shunts

and nonperfusion areas in the macula and infero

temporal retina in the right eye (Fig. 2). The left eye


was normal. She underwent a sector laser

photocoagulation in the right eye. On review, the vision

had improved 6/9, N6 in the right. Fundus was stable

with no new lesion(Fig. 3). On review, after 3 months;

vision was 6/6, N6 in both eyes. Fundus looked status

quo (Fig. 4). On repeat angiogram, more aneurysms

were seen(Fig. 5) for which focal laser was repeated.

On review after 3 months, her vision and fundus are

stable. She has been advised 6 monthly review.

Discussion

Leber’s miliary aneurysm is a form of retinal

telengectasia. The retinal telengectasia are a group of

rare, idiopathic congenital, retinal vascular anomalies

characterized by dilation and tortusity of retinal vessels,

formation of multiple aneurysms, varying degrees of

leakage and deposition of lipid exudates. Retinal

telengectasia always involves the capillary bed,

although arteries and venules may also be affected. The

vascular malformations frequently progress and may

become symptomatic later in life as a result of

hemorrhage, oedema or lipid exudation. This condition

is not associated with any other systemic or ocular

disease.

Leber’s is a relatively severe form of telengectasia which

usually present in adult life with unilateral impairment

of central vision. Fusiform and saccular dilatation of

venules and arteries most commonly involving the

temporal retinal periphery are seen with chronic

leakage resulting in intra retinal hard exudate

formation. Fluorescein angiography highlights the

vascular anomalies. The treatment is by cryotherapy

or photocoagulation to ablate the vascular anomalies.

References

1. Asdourian G: Vascular anomalies of the retina. InPeyman, GA, Sanders, DR, Goldberg, MF, eds: Principlesand practices of Ophthalmology, Vol 2, Philadelphia,1980, WB Saunders.

2. Reese, AB : Telangiectasis of the retina and Coat’sdisease, Am J Ophthalmol 42:1,1956

3. Blodi, FC: Vascular anomalies of the fundus. In Duane,T, ed: Clinical ophthalmology, Vol 3, Hangerstown, MD,1980, Harper & Row.

4. Jack J Kanski.Clinical Ophthalmology-A SystemicApproach 4 th edition.1999 Butterworth Heineman


Managing V Pattern ExotropiaDr. T.S. Surendran MS 1, Dr. Elizabeth Joseph MS 2, Dr. K. Ravisankar MS 3, Dr. Suma Ganesh MS 4,

Dr. Santhan Gopal KS MS 5, Dr. Meenakshi Dhar MS 6

Case1

A case of V pattern exotropia with inferior oblique

overaction in a young patient.

She had a best corrected visual acuity of 6/6 in both

eyes with –1.25 D Sphere given after a cycloplegic

refraction. She had a normal fundus with extorsion of

the macula. On PBCT [Prism bar cover test] in upgaze

horizontal, gaze and downgaze it was 60, 35 and

10 prism diopters on repeated examinations. Patient

had alternate suppression with free alternation.

Bilateral inferior oblique overaction was present.

The plan for surgery was decided. The clinical management

of this patient is based on the following factors:

How is it decided what component of the “V’ is

contributed by the oblique muscle overaction?

How do we decide the surgical plan- The options being

1. Two horizontal muscle surgery with vertical shift of

the horizontal muscles insertion-either bilateral

lateral rectus (LR) muscle recession, or unilateral

medial rectus (MR) resection with LR muscle recession

2. Inferior oblique muscle weakening procedure

3. Both a weakening procedure on inferior oblique with

horizontal muscle recession or resection procedure

with vertical shift of the muscle insertion

If both then what component of the exotropia would

be corrected by the inferior muscle weakening and

horizontal correction should be planned with which

PBCT value in mind.

Strabismus surgery dictums have more or less been well

estabilished, but this is one situation that may be tricky.

Experts in the field of strabismus were consulted and

their views are outlined below. To illustrate the variability

in presentation Case 2 pictures are also attached.

Dr. T.S. Surendran

A good result can be achieved in such patients by taking

the PBCT in horizontal gaze as base line subtracting

15-20 dioptres for inferior oblique overaction and then

correct the horizontal muscles and shift the insertion

1Paediatric Ophthalmolgy, Sankara Nathralaya, Chennai. 2Pediatric ophthalmology

& Strabismus services, Little Flower Hospital, Angamaly 3Sri Ramana Eye Centre,

Chennai, 4Dr. Shroff’s Charity Eye Hospital, Delhi, 5 Strabismus Consultant,

Bangalore, 6 Professor, Amrita Institute of Medical Sciences, Cochin

Case 2: Primary position 30 PD XT, upgaze 40 PD XT, downgaze- 20 PD with bilateral I O overaction.

Case 1:Primary position exotropia 35 PD, down gaze 10 pd,upgaze 60 pd. bilateral inferior oblique overactionpresent.

CONSULTATION

S E C T I O N

December 2008 Consultation Section 431

downwards in case of medial rectus and upwards in

case of lateral rectus one half of its width of insertion.

Do surgery in one sitting combining the horizontal

muscle procedure and oblique muscle weakening.

For a basic exotropia lateral rectus recession 6mm and

medial rectus resection 5mm can be done. Differential

recession of horizontal recti is another useful way of

tackling V pattern. In This for V exotropia the lateral

rectus recession would be more for the superior fibres

so that in upgaze the abduction is weakened more -

exotropia is well controlled.

Dr. Elizabeth Joseph

V pattern eso deviation or exo deviation may be with

or without inferior oblique overaction and success of

surgical procedure depends on accurate assessment and

titration of surgery. Accurate tables are not available

to guide towards proper planning of surgery and every

case should be assessed individually.

First is assessment of the angle of deviation in primary

position, 25 degrees up and down gazes and lateral

gazes to find out the horizontal deviation, amount of V

and whether obliques are overacting. Examine the

versions in extreme 9 positions of gaze to identify any

oblique overaction or underaction and do double

Maddox rod test, to document torsion. In patients with

inferior oblique overaction, there will be extorsion of

fovea as demonstrated by by indirect ophthalmoscope

or fundus photography.

Bilateral weakening of inferior oblique by recession or

myectomy can correct 15 to 20 PD of pattern and will

not affect the horizontal angle in primary position.

Vertical transposition of horizontal recti can correct

about 15 PD of pattern strabismus.

Her Surgical Straegy Is As Follows-

In a patient with primary position horizontal squint

with inferior oblique overaction and the pattern around

20 pd (difference between gaze up and gaze down =20

PD) (as in the second patient whose pictures are shown)

I will correct the deviation in primary position by

horizontal muscle surgery without any vertical shift and

tackle the V pattern by inferior oblique recession. If

the inferior oblique are not tackled in such a patient

the pattern deviation will remain.

If the difference between upgaze and downgaze is as

high as 30-40 PD in a patient with V pattern and inferior

oblique overaction (as in the first patient whose pictures

are given). I will prefer to do inferior oblique weakening

and vertical transposition of horizontal recti to change

the force vector. Some of these patients with a very

large V may have primary superior oblique paresis and

secondary inferior oblique overaction, these patients

present with very large V pattern and may require 6

muscle surgery including superior oblique tucking.

In those patients without oblique overaction , horizontal

muscle supraplacement or infraplacement along with

recess /resect procedure is good enough to correct a

moderate A OR V pattern. Horizontal transposition of

vertical recti combined with horizontal muscle surgery

in large patterns of 40 PD is associated with problems

of anterior segment ischaemia and should be

undertaken only if a vessel sparing technique is

resorted to.

Dr. K. Ravisankar

In this patient 2 aspects of the problem are correction

of the V phenomena and that of the exotropia. Bilateral

inferior oblique weakening procedures correct 15-20º

of the horizontal squint. .Bilateral lateral rectus

recession will correct the horizontal squint, if exotrpia

at distance is 15 PD more than near in primary gaze.

The primary gaze PBCT should be used to calculate

the amount of recession needed. This can be combined

with differential recession of the horizontal recti, where

the superior and inferior ends are recessed in differing

amounts making the musle insertion slanting and not

parallel to the limbus which implies that recession for

superior end of the lateral rectus is more than inferior

end. This further corrects the V pattern strabismus.

The medial rectus is always moved towards the closed

end of the ‘V’ i.e. shifted downwards if its resection is

done. Further the recessed lateral rectus is always

shifted towards the open end of the “V”.

Dr. Suma Ganesh

She also affirmed the viewpoint of doing one stage

procedure - bilateral inferior oblique weakening with

horizontal muscle surgery. Recessing the inferior oblique

would correct 15-20" of exotropia and amount of


horizontal muscle surgery has to be calculated in

primary gaze. The insertion can be shifted half the

muscle width downwards for medial rectus and

upwards for lateral rectus.

Dr. Santhan Gopal KS

In V exotropia with inferior oblique overaction, first

thing is to note the way the recti are inserted.

If one was to imagine a line passing thru the centre of

the eye horizontally, and then see how much of the

insertion of the horizontal recti were above and below

it. There would be the following situations.

A. If LR insertion was either way more superiorly,

i.e. the horizontal line passed through the lower

half of the insertion, there is no point in further

shifting up this insertion for a patient of ‘V’

Exotropia, instead one needs to do the inferior

oblique weakening.

B. If MR insertion was either way more inferiorly,

i.e. the horizontal line passed through the upper

half of the insertion, there is no point in further

shifting down this insertion for a patient of ‘V’

Exotropia, instead one needs to do the inferior

oblique weakening.

C. If the imaginary line passes thru the centre of each

horizontal muscle insertion, shifting the insertions

vertically will help in rectifying the V pattern. The

LR insertion gets shifted half width of the insertion

upwards, and the MR insertion gets shifted

downwards.

D. If LR insertion was either way more inferiorly,

i.e. the horizontal line passed through the upper

half of the insertion, there is point in further shifting

up this insertion for a patient of ‘V’ Exotropia, thus

vertical displacement of the LR insertion would

improve V pattern exotropias.

E. If MR insertion was either way more superiorly,

i.e. the horizontal line passed through the lower

half of the insertion, there is point in further shifting

down this insertion for a patient of ‘V’ Exotropia,

thus vertical displacement by one half of insertion

width would help correcting the V pattern exotropia

He was of the opinion that shifting the horizontal

muscle insertions vertically to correct ‘V’ pattern would

help only if their insertions were either horizontal

orsuperior in MR and inferior in LR.

Exotropia can be corrected as usual with either bilateral

LR weakening or unilateral combined LR rescession and

MR resection, done at the same sitting.

Dr. Meenakshi Dhar

Decision regarding a V pattern exotropia should be

made on the table to a certain extent. Correcting only

the horizontal muscles can help in correcting a small V

pattern in many cases of exotropia, provided all the

check ligaments are released during surgery. This can

be combined with vertical displacement of the insertions

keeping in mind Dr. Santhan’s ideology (as illustrated

above) on muscle insertions. The amount of recession

and resection needed can be calculated taking the PBCT

in primary straight gaze.

Then at a second stage inferior oblique weakening can

be planned if needed. It is surprising to see how many

V patterns get corrected by just doing horizontal muscle

surgery. This leads to lesser surgical manipulation. It is

the long term results with minimal surgical handling,

which should be the goal. Neither the surgeon nor the

patient should be in a hurry.

Of course if the V pattern is large as in case 1, one

stage procedure of horizontal muscle weakening taking

the PBCT in horizontal gaze after subtracting 15 PD

can be done. The simultaneously performed bilateral

IO recession would correct the 15 PD XT.

Conclusion

15-25 % exotropias have pattern strabismus. While

assessing V pattern exotropia oblique muscle overaction

should be looked for. Measurements of deviation should

be taken in all 9 gazes. It could be due to inferior oblique

muscle overaction or superior oblique muscle

underaction or increased action of LR in upgaze or

decreased MR action in downgaze.

Primary and reading positions are functionally the

important positions of gaze. Orbital configuration can

change the force vectors of the extra ocular muscles as

in cases of Crouzon’s and Apert Syndrome. Correction

of these may alter the extra ocular muscle alignment

and action. Thus this should precede muscle alignment.

December 2008 Consultation Section 433

In all cases of strabismus the difference between

primary up and down gaze needs to be calculated.

A difference of 15 PD between up and down gaze makes

it a clinically significant V pattern , while in A pattern

strabismus the difference should be 25 PD.

The presence or absence of inferior oblique muscle

overaction determines the surgical plan. Weakening

inferior oblique corrects 15-20 PD of V pattern.

The horizontal mucles are operated keeping in mind

their original insertions, after good surgical dissection

during their disinsertion for recession or resection

procedures. The musle is reinserted with either slanting

insertions or vertical displacement of one half or both.

A useful mnemonic for the surgical procedures is

‘MALE’: Medial rectus to the apex of the pattern and

Lateral rectus muscles to the empty space.[fig.]. Some

surgeons realign the rectus muscle insertion by placing

the superior corner of say LR and inferior corner of MR

further away from the limbus and other end vice versa-

This is called slanted insertion.

Cases contributed by Dr Elizabeth Joseph, Little Flower Hospital, Angamaly

Compiled and edited by Dr. Meenakshi Dhar, Amritha Institute of Medical Sciences, Cochin

Surgical results are good with functional development

of binocularity, correction of extorsion of the fovea and

decrease in the pattern strabismus of course.

References:

A. Biglan AW. Pattern Strabismus,IN : Rosenbaum AL,

SantiagoAP,eds. Clinical Strabismus Management:

Principles and Surgical Techniques, Philadelphia:

Saunders1999:202-215

B. Ohba M, Nakagawa T. Treatment for A and V strabismus

by slanting muscle insertions. [Binocul Vis Strabismus

Q. 2004] Jpn J Ophthalmol. 2000 Jul-Aug;44(4):

433-8

C. Caldeira JA Some clinical characteristics of V-pattern

exotropia and surgical outcome after bilateral recession

of the inferior oblique muscle: a retrospective study of

22 consecutive patients and a comparison with V-pattern

esotropia. Binocul Vis Strabismus Q. 2004 19(3):

139-50

D. Kamlesh, Dadeya S, Kohli V, Fatima S Primary

inferior oblique overaction-management by inferior

oblique recession. Indian J Ophthalmol. 2002 Jun;

50(2): 97-101


Ernst Fuchs

(1851-1930)Dr. Padmaja Krishnan, Calicut

(In the same year that Helmholtz invented the

ophthalmoscope was born a child destined to be one

of our great ophthalmologists. This is his story…….)

Ernst Fuchs was born in Vienna on 14th November 1851.

He was the eldest of three children.

His ancestors were poor farmers, but his grandfather

was sent to Germany to study Theology initially; he

gave it up to become instead a

Professor of History in Vienna. Fuchs’

father, Adalbert, had an even more

varied career. He started as a medical

student, did a PhD, taught Natural

Science, Zoology and finally

Agriculture in Vienna.

Ernst began his scholastic career at

Scott’s Gymnasium in Vienna in1860,

graduating in 1868. He had an

insatiable thirst for knowledge and

often related the story of how he had,

as a college student, jumped into a

whirlpool to find out for himself if it

were true that the current was strong enough to pull

down the strongest swimmer. He was lucky to survive

this foolhardy experiment.

Fuchs’ father wanted Ernst to be an engineer but the

lad had other ideas. Although his interests included

Physics and Astronomy, he opted to study Medicine.

This he did in the heyday of the Vienna school, being

taught by such luminaries as Joseph Hyrtl, Ernst

Wilhelm von Brücke, Karl Rokitansky, Joseph Skoda,

Christian Billroth, and Carl Ferdinand von Arlt.

While still a medical student, von Brücke recognised

Fuchs’ interest in Ophthalmology and got him a post

as assistant to Otto Becker in Heidelberg, Germany.

Fuchs however chose to go for a year to the

Physiological Institute in Innsbruck.

Here in the Austrian Alps, he developed

his passion for mountaineering, which

remained with him throughout his life.

He returned to Vienna in the fall of

1873 and graduated with honours a

year later.

He began his medical career as an

unpaid intern with von Arlt for whom

he had the greatest respect and

admiration. A few months later von Arlt

suggested that Fuchs start his formal

training in surgery under Billroth,

whose outstanding contributions as a

surgeon were already recognised across Europe. Billroth

was Fuchs’ teacher and mentor for the next two years

at the end of which time Fuchs was tempted to become

a general surgeon himself.

Von Arlt now asked Fuchs to become his assistant and

probably regretting his decision not to train under

Becker the previous year, Fuchs accepted the offer and

returned to Ophthalmology. Five years later and just

30 years of age, he became Professor of OphthalmologyComtrust Hospital, Calicut

OPHTHALMICH I S T O R Y

December 2008 Ophthalmic History 435

at Liege, Belgium; at that time he was the youngest

Austrian-trained graduate to become a professor.

In 1885 he succeeded Eduard Jaeger Ritter von Jaxtthal

as Clinical Director of the Second Vienna Eye Hospital.

Fuchs had already published his prize winning book

on the causes and prevention of blindness. His

worldwide reputation as a lecturer and physician

started with this appointment.

In 1915, aged 64 years, Fuchs resigned as clinical

director of the Second Vienna Eye Hospital. The main

motive for his relatively early retirement was apparently

to escape from the time-consuming obligations of

teaching and examining. Nevertheless, following

retirement he published a further 99 articles.

During the time he was at Vienna, ophthalmologists

from around the world came there to learn from the

man considered the master of their profession. Fuchs’

extensive clinical studies and histopathologic

observations provided the first descriptions and

definitions of many conditions and diseases of the eye,

including Fuchs endothelial dystrophy, Fuch’s

heterochromic cyclitis, Dalen –Fuch’s nodules and

Fuch’s coloboma to name a few. He changed the custom

of keeping patients in a dark room with both eyes

covered for a whole week before changing dressings

after a cataract operation. He also introduced early

ophthalmoscopic examinations in these patients and

thus found that choroidal detachment was far more

common than previously believed.

His Textbook of Ophthalmology, first published in 1889,

was regarded as the “bible of ophthalmology” for more

than 50 years. He developed this from his lectures to

ensure that his students listened to him rather than be

distracted making notes. It was a classic in its time and

published in all European languages as well as Japanese

and Chinese. Fuchs employed the then new technique

of using large print for material suitable for students

and small prints for that which he felt was important

for people who were continuing to study ophthalmology

as a postgraduate exercise. It ran into eighteen editions

in German within the next twenty-one years. Of these,

twelve were edited by Fuchs himself and the later ones

by his oldest pupil, Salzmann. And the rapid progress

made by ophthalmology in that period made Fuchs

write in his preface to the tenth edition, “Nothing shows

me the speed of scientific progress better than to leaf

through the first editions of my book. I come across

opinions that I shared with other experts and that now

seem to have aged half a century. I would prefer not to

admit to these opinions, would the proof not lie in front

of me.”

This text proved to be a very important work at that

time and was translated into various languages

including Japanese, Chinese and Russian. The last

German edition was published in 1945. Ten British

editions appeared between 1892 and 1933. In 1903,

Alexander Duane translated and published this in the

United States as Fuchs’ Textbook of Ophthalmology –

this popular text ran into eight editions.

Ernst Fuchs was famed for his teaching abilities

throughout his career but especially during the last 15

years of his life, which he spent traveling to teach and

visit his pupils around the world.Thanks to numerous

invitations by international colleagues, scientific

societies, and governments, Fuchs was able to escape

the Austrian winters (of which he had a growing dislike

with age) by speaking in countries as far away as

Indonesia and East Africa. Remarkably, besides some

knowledge of Latin and Greek, Fuchs was fluent in

English, French, and Italian. To present his work in

Spain and South America, he also began to learn

Spanish at age 70 years and subsequently produced

several publications in that language.

Fuchs was a tall man with a slight stoop. He embodied

Osler’s ideals of equanimitas by never being angry or

impatient and maintaining a calm and unruffled

exterior. He was fluent in English and German and this

helped him to communicate with and present papers

to scientists all over the world.

Apart from his interest in medicine, Fuchs was

interested in Botany, Geography, Literature, Art and

History. He enjoyed travelling till the very end and was

a member of the Vienna Geographical Society. He

regularly gave talks to a wide audience on his many

travels around the globe. In 1875 he returned from

Scandinavia with a pair of “snow shoes” and thus

introduced skiing to Vienna.

In recognition of Fuchs’ worldwide reputation a special

banquet was held in his honor by the American

delegation at the Amsterdam International

Ophthalmological Congress in 1929. It was at this


congress that the International Association for the

Prevention of Blindness was established and Fuchs was

elected it’s first honorary member. From the

Netherlands, he traveled to Canada and then to

Baltimore, where he was guest speaker for the opening

of the Wilmer Ophthalmic Institute. Fuchs then

journeyed through Mexico and Central America.

A few months after his return to Vienna and following

an outstanding, dynamic career, Ernst Fuchs died of a

heart attack on November 21, 1930, at age 79 years.

He was buried in Kritzendorf, a small Austrian village

on the Donau River.

During the funeral oration held by the Austrian

Ophthalmological Society, of which he had been

President of Honor, Fuchs was described as a serious

teacher and physician who was never dogmatic and

never taught anything he was not certain of. Great

encomiums indeed!!

December 2008 Journal Review 437

Prevalence of Glaucoma in Patients With

Obstructive Sleep Apnoea -

A Cross-Sectional Case-SeriesRE Bendal, J Kaplan, M Heckman, PA Fredrickson, Eye 2008, 22: 1105-1109.

Loss of integrity of the optic nerve is the key in the

pathogenesis of glaucoma. Several reports suggest the

importance of vascular risk factors, especially in normal

tension glaucoma. Obstructive sleep apnoea (OSA) is

a condition characterized by recurrent upper airway

obstruction accompanied by hypoxemia, hypercapnia,

and sleep disruption. Untreated OSA has been

implicated in the development of cerebral ischemia,

myocardial infarction, pulmonary hypertension, and

cardiac rhythm disturbances, all potential factors in

optic nerve ischemia.

In this study the authors from Mayo Clinic, aim to

determine the prevalence of glaucoma in patients with

obstructive sleep apnoea. This is a cross sectional case

series and includes one hundred patients with moderate

to severe obstructive sleep apnoea. Within 48 hrs of

the polysomnographic diagnosis of obstructive sleep

apnoea, patients underwent following tests: intraocular

pressure, gonioscopy, automated perimetry,

stereoscopic biomicroscopy, and fundoscopic

assessment for the presence of glaucomatous optic

nerve changes.

Glaucoma was diagnosed in 27 of 100 patients yielding

an estimated prevalence of 27 %.(95 % CI 19-37 %).

The presence of glaucoma did not correlate with sex,

body mass index, or AHI, but did appear to be

associated with age (P=0.014). There was no evidence

of a relationship between intraocular pressure and

either the apnoea plus hypopnoea index or age.

This study revealed an unexpected high rate of

glaucoma in patients with obstructive sleep apnoea.

The authors admit that the study design has the

potential to introduce bias since the eye examinations

were carried out with the knowledge that all the

patients had obstructive sleep apnoea.

J OURNALR E V I E W


Fibrin Glue Versus Sutures for Conjunctival

Autografting in Pteryium Surgery:

A Prospective Comparative StudyA karalezil, C Kucukerdonmez, Y A Akova, R Altan-Yaycioglu, M Borazan

Br J Ophthalmol 2008;92:1206-1210.

Conjunctival autografting after pterygium excision is

associated with very low rates of recurrence and

complications when compared with other techniques.

The surgeon’s skill and experience affect the recurrence

rate, which varies between 2 % and 39 % with this

technique. Nevertheless, because of graft suturing, this

method has the disadvantage of a relatively longer

surgery time when compared with the bare sclera

technique; also it carries the risk of complications such

as granuloma formation and giant papillary conjunctivitis,

as well as significant patient discomfort after surgery.

In the this study, the authors from Ankara,Turkey,

sought to determine the safety and efficacy of using

fibrin glue (Tisseel VH, Baxter AG, Vienna) to attach

conjunctival autografts and to the results of such with

the use of Vicryl sutures in patients undergoing

pterygium excision. This is a prospective, randomised

study to evaluate operation time, postoperative patient

comfort and pterygium recurrence.

Fifty consecutive patients (50 eyes) with primary nasal

pterygium were enrolled in this prospective study.

Patients with immune system, eyelid or ocular surface

diseases (eg, blepharitis, Sjögren syndrome and dry

eye), with a history of previous ocular surgery or trauma

or known hypersensitivity to any component of fibrin

glue were excluded from the study. Patients were

randomised to two groups. To reduce intra-observer

bias and minimise the influence of the known surgical

technique on the extent of removal and size of the graft,

the randomisation was done after the surgeon (AK)

had harvested the graft. Postoperatively, patients used

dexamethasone 0.1 % and tobramycin 0.3 % eye-drops

four times a day for 7 days, and three times a day for

the following 10 days. All eyes in both groups were

covered with an eye shield for 10 days. Patients were

examined on the first and 10th days, and also at the

first, third, sixth and 12th months after surgery. In the

suture group, sutures were removed 10 days after the

surgery.

Patients were asked to fill out a questionnaire on

postoperative day 1 and during every follow-up

examination until the first month, grading their symptoms

(pain, foreign body sensation, irritation and epiphora)

using a five-point scale adapted from Lim-Bon-Siong

and associates, in which 0 means none, or no symptoms;

1 means very mild, or presence of the symptom but

that it is easily tolerated; 2 means mild, or that the symptom

causes some discomfort; 3 means moderate, or that

the symptom partially interferes with usual activities

or sleep; and 4 means severe, or that the symptom

interferes completely with usual activities or sleep.

Statistical analyses were done with SPSS software. The

Mann-Whitney U and chi-square tests were used for

statistical analyses. A p value less than 0.05 was

considered statistically significant. No significant

difference was found between the two groups with

regard to sex or age (p > 0.05). The mean duration of

surgery was 15.7 (SD 2.4) min (range 12-18 min) in

the fibrin glue group, and 32.5 (6.7) min (range 25-40

min) in the suture group. The operation time was

significantly shorter in the fibrin glue group than it was

in the suture group (p < 0.001). The intensity of the

postoperative complaints including pain, foreign-body

sensation, irritation and epiphora was significantly

lower in patients treated with fibrin glue than in those

treated with sutures at both postoperative days 1 and

10 (p < 0.001). Also, the intensity of itchy sensation

at the first two postoperative visits was lower among

patients in the fibrin glue group (five patients, 20 %)

than in the suture group (12 patients, 48 %) (p < 0.05).

After suture removal in the suture group at

postoperative day 10, all symptoms disappeared quickly.

December 2008 Journal Review 439

None of the patients had any complaints of epiphora

or pain at day 30. Only a few patients in both groups

still had mild irritation and foreign-body sensation in

their eyes at day 30; however, there was no statistically

significant difference between the two groups (p > 0.05).

Reviewed by Dr. Radha Ramanan DO DNB, Little Flower Hospital & Research Center, Angamaly

The authors conclude that, the use of fibrin glue in

pterygium surgery with conjunctival autografting

significantly reduces surgery time, improves postoperative

patient comfort and results in a lower recurrence rate

compared with suturing.

Changes in Angle Configuration After

Phacoemulsification Measured by Anterior

Segment Optical Coherence TomographyWinifred P. Nolan, Jovina L See, Tin Aung, David S Friedman, Yiong-Huak Chan,

Scott D Smith, Ce Zheng, david Huang, Paul J Foster, Paul T K Chew

Journal of Glaucoma. 17(6):455-459, September 2008.

Cross-sectional imaging of the anterior segment and

angle has become more sophisticated over the last 5 to

10 years. Recently optical coherence tomography (OCT)

technology has been adapted for the use in imaging

the anterior segment (AS-OCT). The aim of the study

was to measure changes in angle width after

Phacoemulsification and intraocular lens (IOL)

implantation using anterior segment optical coherence

tomography (AS-OCT).

Twenty-one patients undergoing cataract surgery were

recruited from the National University Hospital,

Singapore. AS-OCT images were obtained of nasal and

temporal angle quadrants before and at 1-month after

surgery. Optical measurements of central anterior

chamber depth were obtained, and gonioscopic

measurement of angle width was recorded. AS-OCT

angle width parameters measured in the nasal and

temporal quadrants included the angle opening

distance at 500 [μm] (AOD500) anterior to the scleral

spur and the trabecular iris surface area at 750 [μm]m

(TISA750) anterior to the scleral spur. Preoperative and

postoperative measurements were compared using

paired samples t tests.

Data were collected from 21 eyes of 21 subjects with

cataract. Seven subjects also had gonioscopic evidence

of primary angle closure. Mean anterior chamber depth

increased from 2.92 (+/-0.54) to 4.24 (+/-0.57) mm

(P=0.044) after cataract extraction. There was a

significant increase in AS-OCT parameters for both

nasal and temporal angles after surgery. An 88.2%

increase in AOD500 was measured for the nasal angle

quadrant with a mean difference of 213.9 (+/-173)

[μm] (P<0.001). TISA750 increased by 94.4% in the

nasal angle with a mean difference of 0.134 (+/-0.104)

[μm] (P<0.001).

This study demonstrates how AS-OCT imaging can be

used to measure changes in angle configuration after

cataract surgery. It confirms that angle widening of up

to 80% can occur when the lens is removed. The authors

conclude that AS-OCT imaging quantitatively

demonstrates increases in angle width after cataract

extraction.


Mastering the Techniques of LASIK,

EPILASIK and LASEK (Techniques and

Technology with DVD-ROM)Edited by Ashok Garg, Jorge L Alio, Bojan Pajic, Cyres K Mehta

Published by Jaypee Brothers New Delhi

First edition-2007

Price Rs: 1795/-

Rapid strides have been made in the field of Corneal

Refractive Surgery in the relatively short span of the

last decade. With the advent of new laser machines

and techniques a new paradigm shift in Ophthalmology

was introduced regarding refractive surgery. Excimer

Laser Surgery provides an accurate tool to reshape the

cornea to correct refractive errors in a successful

manner. Ten years ago only Excimer Lasers were

available but now Broad beam, Slit beam, Spot Lasers

and Solid State Laser have revolutinized the Corneal

Refractive Surgery Treatment. The leading factors that

have influenced the changing phase of Corneal

Refractive Surgery have been knowledge gained from

the experience and improvements in technology that

have implemented that knowledge. New Wavefront and

Topography guided Lasik system, Epilasik and Lasek

techniques that have evolved in recent years have not

only helped design better ablation profiles for individual

patients but also provided a more objective means of

measuring outcome resulting in improved algorithms

for future treatments.

With accumulated experience and with the application

of more sophisticated techniques, the safety and efficacy

of refractive surgery has considerably increased during

the recent years. In addition, patient’s satisfaction and

complaints together with the doctor’s clinical

suggestions are being long-term investigated in order

to determine the maximum efficacy after refractive

surgery. The initial enthusiasm is replaced by a more

systematic approach, which contributes to better results

leading to increasing patient’s satisfaction and

physician’s confidence. In this concept, this book is

timely and concise on the many interesting entities of

LASIK technique while the large collection of esteemed

authors and chapters stimulate the reader to search in

the literature for additional contents. It is thoroughly

researched and easy to read.

This international book contains 46 chapters covering

all aspects of practical Lasik, Epilasik and Lasek techniques.

A galaxy of top international Lasik Experts have shared

their experiences in form of chapters for the benefit of

those ophthalmologists who want to start these techniques

in their practice. A video DVD Rom is being given with

this book showing latest Lasik, Epilasik and Lasek

techniques by International Master of this field. As the

clinical practice of Lasik, Epilasik and Lasek is on the

rise world wide, this book shall provide useful practical

tips and guidance to every interested ophthalmologist.

B O O KR E V I E W

December 2008 Book Review 441

The Sankara Nethralaya

Atlas of Ophthalmic UltrasoundEdited by; Muna Bhende, Sriram Gopal, Anuj Gogi, Tarun Sharma, Lingam Gopal,

Lekha Gopal, Parveen Sen, Smitha Menon


First Edition- 2006

Price Rs: 1595/-

Although ophthalmic ultrasound is now widely

accepted as an important tool for the diagnosis and

management of many ocular and orbital disorders, most

academic centers do not have formal training programs

to teach the skills necessary for performing precise and

accurate ultrasound examinations. Unless an individual

can spend several months or more at one of the few

centers in the world that have an expert echographer,

most ophthalmic ultrasound is self-taught by attending

lectures, reading articles and studying one of the few

textbooks available in this field. A welcome addition

to the collection of teaching materials currently

available for ophthalmic ultrasound is The Sankara

Nethralaya Atlas of Ophthalmic Ultrasound.

The Ultrasonography department at Sankara

Nethralaya consists of ophthalmologists, most of whom

are trained vitreoretinal surgeons. The department

performs about 40 procedures every day and has been

doing so far almost two decades. The atlas is a

compilation of the numerous classic and unusual cases

that have been here, along with a brief outline of the

salient clinical and ultrasound features. The nuggets

at the end of the chapters are intended to serve as a

quick reference in difficult situations.

This group, consisting of mainly vitreoretinal surgeons

who are also experienced echographers, has put

together a concise, yet comprehensive text that is

extremely well illustrated very readable. Excellent

examples of almost every ocular and orbital disorder

one might expect to encounter in the clinical practice

of ophthalmic echography are represented in this atlas.

The reader’s understanding of the ultrasound illustrations

is enhanced with color fundus photographs and external

photos, as well as CT scans and MRI scans of the orbit.

One of the text’s outstanding features is the use of

“nuggets” in most of the chapters; charts which provide

pearls of information that are important for the

differentiation and diagnosis of particular conditions.

This book have 50 chapters in 9 sections which includes

topics like getting started, Vitreo-retinal diseases,

Trauma, Infections and inflammations, Tumors,

Congenital anomalies-Disorders of Paediatric age group,

Surgical considerations and Orbital lesions.

This atlas is meant as both a basic text as well as reference

tool for both students of ophthalmology, practicing

ophthalmologists and will be of great interest to those

already familiar with ultrasound of the eye and orbit.


Sankara Nethralaya’s Atlas of Uveitis and

ScleritisEdited by: Sudha K Ganesh, Mamta Agarwal, Amala E George, Jyotirmoy Biswas

Published by: Jaypee Brothers, New Delhi

First edition: 2006

Price Rs: 1695/-

Anterior Segment Imaging in

Ophthalmology Ultrasound Biomicroscopy,

Anterior Segment OCT, Pentacam with

DVD- ROMEdited by Tanuj Dada, Ritu Gadia, Sujith Vengayil, Anand Aggarwal, Ramanjit Sihota


First Edition; 2008

Price Rs: 995/-

surface disorders, Lens, Glaucoma, Imaging of ocular

neoplasms, Evaluations of ocular trauma, Vitreoretinal

applications, Utility in cornea and lens based refractive

surgery, corneal transplant surgery and cataract surgery

with over 200 illustrations and photographs.

This text is well- structured, clearly written, well

illustrated and includes a DVD demonstrating the “how

to” of these techniques in a practical and helpful

manner. Trainees, ancillary eye care workers and

ophthalmologists alike will find this publication useful,

easy to read and helpful as a clinic reference manual.

Hospital and clinic administrators will be able to judge

the value of adding these new technologies to the

service they currently provide.

The readers will find the present text informative,

helpful in their clinical practice, will enjoy and benefit

from this publication.

Innovative technology for anterior segment imaging has

become available in recent times that have

revolutionized diagnostic ophthalmology. The three

major technologies that are now in use include

Ultrasound Biomicroscopy (UBM), Anterior Segment

Optical Coherence tomography (ASOCT) and

Seheimpflug photography using the Pentacam. These

investigations have impacted several ophthalmic

subspecialties and now play a vital role in the diagnosis

and management of various corneal and ocular surface

disorders, congenital and acquired lenticular abnormalities,

ocular neoplasia, ocular trauma and glaucoma.

The topics of this text includes; Basic principles of

imaging, Salient features of machine, Methods of

examination, Quantitative evaluation and biometry,

Indications for use, Clinical applications in congenital

disorders, Ocular adnexal imaging, Corneal and Ocular

Uveitis is an emerging subspeciality of ophthalmology

that presents with a constellation of clinical findings.

Accurate diagnosis of uveitis and successful treatment

of these patients remain a challenge. The field of uveitis

has been revolutionized over the past 50 years. Our

understanding of the ocular inflammatory diseases has


progressed rapidly and we can accurately diagnose and

treat these disease. Basic science and research in

immunology has led to new therapeutic approaches to

the patient with uveitis and scleritis.

In recent years, molecular diagnostic procedures have

detected infectious agents in some cases wherein

organisms could not be cultured or detected by

microbiological procedures. Among the various

molecular procedures used, the analysis of intraocular

fluid by polymerase chain reaction (PCR) in uveitis has

shown great promise in detecting traces of an infectious

agent in the form of a microbial specific DNA sequence.

This procedure has been successfully used by several

laboratories including laboratory of Sankara Nethralaya

to detect bacteria, viruses and protozoa in intra ocular

inflammation.

This atlas gives the reader a concise overview of the

clinical manifestations, investigations, diagnosis and

management of uveitis and scleritis. The authors

emphasize on careful clinical assessment and accurate

diagnosis. This book is not intended to be a textbook

but a practical guide to the diagnosis, in obtaining

appropriate investigations and management. The uvea

department of Sankara Nethralaya has a team of four

consultants and they examine about a thousand new

cases of uveitis every year. The emphasis on maintaining

good clinical record with digital archiving was an

excellent source for selecting pictures for this atlas. All

cases included were patients seen at Sankara

Nethralaya, Chennai.

Based on well documented clinical findings, laboratory

investigations including PCR analysis, the authors of

this well illustrated atlas provide succinctly, the main

clinical diagnostic features and management of various

uveitic entities. Profusely illustrated clinical examples

of both anterior and posterior uveitis and scleral

inflammation serve as a guide to postgraduate students

who are in the process of acquiring knowledge in the

field of uveitis, a leading cause of blindness in the

developing world.

Mastering the Techniques of

Presbyopia SurgeryEdited by: Ashok Garg, Jairo E Hoyos, Guillermo Avalos Urzua, Roberto Pinelli, Keiki R Mehta, Matteo Piovella

Published by: Jaypee brothers, New Delhi

First Edition: 2006

Price Rs 1595/-

The mechanism and cause of presbyopia are not fully

understood. In fact competing theories about what is

happening to the lens and the zonules during

accommodation have led to very different cures.

There is sizable population of presbyopics in the world.

Majority of them are not interested in wearing

presbyopic glasses or contact lenses in the long run.

The restoration of reading vision in presbyopia is one

of the most important component of modern refractive

surgery. For the last five years a massive research work

is being done on lenticular, corneal and scleral

modifications to correct presbyopia with encouraging

results. Multifocal Presbyopic LASIK, Conductive

Keratoplasty, Multifocal Presbyopic Lenses are in

widespread use already. A lot of work is being done on

laser and injectable intraocular lenses for restoration

of accommodation which has met with initial success.

Use of accommodative implants, multifocal implants,

Refractive Lens Exchange and Blended Vision Implants

are lenses based refractive surgery procedures which

are quite successful in restoring reading vision in

presbyopic patients.

This book on presbyopia has been written through a

team effort of leading International refractive surgeons

with the purpose of providing latest knowledge on

modern lens and corneal based refractive techniques

of presbyopic correction to ophthalmologists who are

interested in presbyopia surgery practice. Forty-one


chapters in four section of this book are written by well

known international refractive surgeons sharing their

knowledge and skill covering all aspects from

physiology to various LASIK/lens based techniques,

complications management, recent advances and future

prospects. An Interactive CD Rom is being provided

with this book showing various operative techniques

in presbyopia by masters of this field.

In the first section of this textbook, leading experts from

around the world discuss presbyopia as a condition and

look at appropriate preoperative evaluation and

considerations in recommending treatments for the

presbyopic patient. In section II, more than two dozen

authors explore the rich variety of techniques for

correcting presbyopia. These include lenticular, corneal

and scleral approaches to restoring accommodation or

pseudo-accommodation. Some of them including

conductive keratoplasty and multifocal LASIK are in

widespread use already. Others are still early in the

developmental stages, but one can find excellent ideas

and pearls from the top authorities on the subject in

these pages. Finally, the book closes with a section on

complication management in presbyopia surgery, and

future considerations for technology that may be the

next big step.

This book provides comprehensive and latest

information on presbyopia correction to every

interested ophthalmologist.

Compiled by Dr. C. V. Andrews Kakkanatt, JMMC Thrissur


NATIONAL CONFERENCE

Vitreo Retinal Society of India Conference

4th -6th December 2008

Venue: Raichak, West Bengal

Contact: Dr.Mangat R.Dogra

AIOS

67th All India Ophthalmological Conference

(Maru Jyothi)

5th – 8th February 2009,

Venue: Jaipur

Contact: Dr.P.K.Mathur (Organising Secretary)

C-126, Moti Marg, Bapu Nagar, Jaipur

Ph:0141-5131236/37

Fax 0141-2221695

Upcoming CME

INTERNATIONAL CONFERENCE

ASIA-ARVO 2009

International Meeting on Research in

Vision and Opthalmology

January 15-18, 2009

Venue: Hyderabad International Convention Center

Hyderabad, India

Contact: Santosh G Honavar

MEACO 2009

Middle East African Council of Ophthalmology

26-30 March 2009

Bahrain

www.meaco.org

UPCOMING

C M E


OCT IN MACULAR DISORDERS

• Non Invasive, Non Contact• High Resolution

• Cross Sectional Imaging Technique

• Morphology of OD, Fovea, Layers of Retina

• 2.1 /3/10 micron Resolution

• Valuable in Teaching

• Optical Biopsy Imaging - Without Excisional Biopsy

UTILITY

• To Identify ERM

• Confirm Presence of Macular Hole

• Differentiate MH From Simulating Lesions

• Identify - Macular Holes

- Macular Cysts

- Vitreomacular Traction

- Presence of SRF ;PED;CNVM

• Quantify Macular Oedema

• Measure Retinal Thickness Changes in Responseto Therapy

Optical Coherence Tomography in

Macular DiseasesOCT

� Based on Principle of Optical Reflectometry

� Ultrasound using Light

� Original Concept was Optical Biopsy : Non –

Invasive Way to Define Ultrastructure of Optical

Tissue

� OCT 1,2,3,& 4 : Resolution Of 8-10 micron

…………….Still Unable to Perform a True Optical

Biopsy

P G T E A R

S H E E T


SURGICAL DECISION MAKING

• Characterises ERM: Location, Extent, Thickness,Attachment Points, Multilaminar, Pseudoholes

• Visualising Surgical Approach• Prognosticate Post op Visual Acuity• Macular edema, Asso Lamellar MH, Degree &

Location of Perifoveal Traction, Presence of CMERisk of Iatrogenic MH

• Post op Evaluation of Slow Visual Recovery• ERM :Presence / Regrowth,Macular Oedema

OCT IN MACULAR HOLES

• As an Adjunct in the Diagnosis ofDifficult to examine patient

• Certain Media Opacities• Coexistent ERM• Suspicion of a tiny hole• Lamellar vs Full Thickness Hole• Thin walled Cyst vs Hole

OCT IN MACULAR HOLES

• Macular Pseudoholes &Lamellar Holes� Contour of Foveal Pit� Thickening of Edges� Steep Foveal Contour� Presence of Normally

Reflective Retinal Tissueat Base

DEFORMATION OF RETINAL PROFILE

• Macular Holes

• Pathogenesis

� Staging

� Natural Course

� Treatment Implication

� Differential Diagnosis

� Patient Education

� Post Surgical Confirmation of Closure

PATHOPHYSIOLOGY• Importance of

VitreomacularTraction inthe creation ofMacular HolesHas Been Recognised For Years

Anteroposterior Transvitreal Traction

• Tangential Traction Theory of Gass

SCREENING : FELLOW EYE• Can Document Progression of VMT• Progression to MH

in Fellow EyeWithout PVD

4.6 % in 3 Years6.5% in 5 years7.1 % in 6 years

With PVD : 0%

MEASUREMENT OF HOLE FORM FACTORa = BASE DIAMETER OF HOLE = 932 micronb = MINIMUM HOLE DIAMETER = 649 micronc = LENGTH OF LEFT ARM = 280 micrond = LENGTH OF RIGHT ARM = 333 micronHFF = c+d/a = 280 + 333 /613 = 0.65

OCT VALUE IN MHS• Operative Planning & Prognosis• Hole size & centration• Presence & degree of surrounding cystoid change• Degree of macular detachment• Asso ERM• Degree of underlying RPE change

POST MHS

• Confirmation of Hole Closure• Visual Prognosis

(Imaii .M , Iijima,H,Gotoh .TAm .J. Oph 1992,128,621 – 627)� U Pattern : Normal Foveal Contour� V Pattern ; Steep Foveal Contour� W Pattern: Foveal Defect Of Neurosensory

Retina U>V>W (Visual Prognosis)


ROLE OF OCT IN DME

Sensitive Diagnostic Test

� Early Detection of DME

� Monitor DME

� Prognosticate

� Can Reveal CME, Subfoveal Serous RD,VMT

which cannot be detected by FFA

Detects Mechanical Contribution

VM Interface Abnormalities

Thickness of Macula

Presence of ERM

Compiled by Dr. Meena Chakrabarti MS DO DNB, Chakrabarti Eye Care Centre, Trivandrum

OCT IN DME

• Separates DME with VR Interface abnormality :VMT, Coincident ERM, Taut ILM

• Explains why these eyes respond poorly topharmacological & Laser therapy

• Defines indications for PPV• Longitudinal tracking of tissue changes following

an intervention

OCT IN VMT• Points of attachment• Evaluation of clinically inapparent VMT• Preop Counseling: cystoid

change, foveal traction,schisis, distorsion of fovealarchitecture, intra retinaloedema, foveal detachment

ARTIFACTS & LIMITATIONS Preintepretation check list

REPRODUCIBILITY

HUMAN• Operator experience• Pt co-operation• C o m m u n i c a t i o n

between doctor &operator regardingarea of interest

MACHINE• Registration

• Scan type: points, fastscan, scan length,horizontal/vertical

• Image quality & signalstrength (<5 : do notjudge), iris clip,capture error

• Measurements :algorithm confidence

• Serial OCT in Followup of Retinal Diseases

• Post OperativeConfirmation of• Accurate• MH Closure• Release of VMT• Resolution of DME• Inter Observer

Reproducibility• FP - OCT Overlay

• Accurate• Precise• Repeatable• Reproducible

DISADVANTAGES OF OCT

• Degradation of ImagesIn Presence of Media Opacities

• Scan Quality = depend on Skill of Operator• Impossible in Uncooperative

Children• Measurements Incorrect if

Scan is Not Centered

OCT & MHS : POSTOP ISSUES

• Suboptimal Visual Results• Persistent foveal detachment• Persistent macular oedema• Reduced central foveal thickness• Late Drop in Vision• ERM formation• Distorsion of foveal architecture• Hole reopening

DECISION MAKING IN AMD

• FFA can determine lesion size, location, type &leakage

• OCT : shows compartmentalisation of fluid thatleaks from CNVM : ME, SRF, PED

• OCT : an adjunct to FFA …….interpretation ofleakage, response to therapy

• Useful in ambiguous cases: ME,Early RAP, EarlyRPE tears,Location of blood: subretinal /subRPE

• Non AMD causes of vision loss : MH,VMT,ERM• Conditions Mistaken for AMD : CSR,IPFT

OCT IN AMD

• In the age of antiangiogenic therapy

• Ideal for designing treatment strategies : When

to stop ? When to restart?

• OCT : can identify leakage from CNVM,

resolution of, recurrence of leakage

• What is the future of FA?

• Anti Angiogenic Therapy is effective across all

lesion types ……..it is not the lesion but the

leakage that has to be monitored……..if it is the

leakage that matters …….OCT is all that is really

needed to plan treatment strategies & for

followup


GENERAL INSTRUCTIONS TO AUTHORS

The Kerala Journal of Ophthalmology (KJO) is a quarterly; peer reviewed one, devoted to dissemination

of the latest in ophthalmology to the general ophthalmologists as well as to specialists in the various

subspecialties of this discipline. It invites submission of original work dealing with clinical and laboratory

materials.

Authors submitting materials to this journal are requested to adhere STRICTLY to the norms laid down

below. The matter must be typed on one side of the paper. A margin of I” must be left all around and the

material must be double-spaced. A page should contain not more than 25 lines. Two copies of the text in

paper and one copy in a CD must be submitted to the Editor and the corresponding author is advised to

keep another copy with him. The corresponding author must give it in writing in his covering letter that

the same matter will not be submitted elsewhere if accepted. He must also enclose the copyright transfer

of his work to this journal. The papers sent will be subjected to peer review. The accepted manuscripts

become the permanent property of this Journal. The author is informed that, if his work is returned to him

for correction / clarification after peer review, he should effect the same and send the manuscript back to

the Editor within one month. Each manuscript component mentioned here under must begin with a new

page and the pages are to be numbered at the right tip corner starting from the Title page.

1. TITLE: The title of the work must be brief and precise. It should not exceed two lines and 40 characters

(including comma, period) Author (s) full name (s) must be given along with his (their) degree and

the affiliations. Corresponding author’s name, correct address (including e-mail and Fax, if available)

and phone number must be mentioned at the bottom left hand corner of the first page.

2. ABSTRACT: The abstract is to be given in the beginning itself. It should not exceed 200 words. It must

contain the aim, methodology, results and conclusion. For case report, summary / conclusion alone is

to be given.

KEY WORDS (maximum five) in capitals are to be included at the end of Abstract.

3. INTRODUCTION: Describe the aim of the study, along with the hypotheses that were tested. Only

necessary references are to be given

4. METHOD: Give in detail the materials used and the methods employed. Describe the type of study.

Pharmacological names only must be mentioned for the drugs used and, if proprietary name is used,

then the manufacturers name must be given in parentheses. Except for standard, well-accepted

abbreviations (Including SI Units), all others must be introduced in parentheses when the full term is

used for the first time in the article.

5. RESULTS: Give only the results obtained by the study under discussion. State the statistics in the

correct scientific form (P value, mean etc). Results based on assumptions must not be given. Indicate

in the text the place where the tables have to be inserted

6. DISCUSSION: The discussion should be to the point and relevant to the subject under discussion.

This section can be combined with the previous one if the author desires. Avoid speculations. Use

only standard abbreviations or the abbreviations already introduced.

7. ACKNOWLEDGEMENT: This is to be made only to those who were directly and scientifically involved

with the preparation of the paper. Permitting authorities, technicians, photographers who assisted in

the work need not be mentioned.


8. REFERENCES: The references should be given in numerical order in which they first appear in text

and not in alphabetical order (Citation Order System). It should be numbered consecutively in the

text. The references will not be checked by the Editor or by the Peer reviewer and hence the author is

solely responsible for its completeness and the accuracy. Period should not be employed anywhere in

the references. Personal communication, unpublished data and poster references, if mentioned, should

be in the text itself and the source mentioned in parentheses. References should be in the following

form:-

Journal reference: Author(s) full title, Journal name (as abbreviated in Index Medicus), volume number,

pages and year. If there are more than three authors, then mention the first three authors and then ‘et

al’.

Book reference: Authors(s) (& Editor, if any), title of book (and chapter), publisher, place of publication,

page number (s) of the cited portion and year.

9. THE LEGEND: The legend for the illustrations (and tables, if necessary) must be given in a separate

sheet of paper and should be typed double-spaced.

Illustrations: The photos and figures should be prepared in glossy prints with good contrast and of the

size 6” x 4”. Only salient details should be included. On the back of the illustration, the figure number

in text, title of the paper, the first author’s name and the top side (marked with an arrow) must be

specified. Except for arrows, no text is to be on the photos. It is the duty of the author(s) to get the

patient’s written permission when the subject is identifiable in the photo. Submit two sets of illustrations.

Illustrations from other Journals and books are usually not accepted. If used, it rests with the author(s)

to get the copy right permission from the original author / publisher and this permission letter must

be sent to the Editor at the time of submitting the manuscript. For Histological figures the stain and

magnification used should be noted e.g.: - H & E Stain x 70.

10. TABLE: It should be in double space. Each table must have an Arabic numeral (except for single

table) and a title both in a single line. Each column in the table must have a short heading. If a table

is large, then it must be continued in a second page, which also must have the table number and the

title. Avoid vertical lines in the tables. Two sets must be submitted.

The manuscripts are to be sent to The Editor by Courier Mail or by Registered post. The corresponding

author will receive communication from the Editor within two weeks of receiving the manuscript.

11. All manuscripts are subjected to editorial board review.

12. Other Categories of Manuscript

a) Original Articles should generally not exceed 3,000 words or 12 double – spaced pages.

b) Review Articles: can be on topics of relevance to clinical practice, research methodology, community

ophthalmology or investigative work, of relevance to visual science. These articles should include

up to date review of existing literature, and summarize the current status / preferred practice for

that particular topic.

Brief reports are short communication of new instruments, new laboratory techniques or surgical

techniques as well as interesting case reports with unique findings. These should not exceed 1000

words with a maximum of 2 illustrations. They should follow the format - introduction, case, and

discussion. No more than 8 references should be cited. Each brief report must begin with a 75-100

word summary that highlights the significance of the articles.

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